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Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy and Planning 2010;25:104–111 ß The Author 2009; all rights reserved. Advance Access publication 16 November 2009 Integration of targeted health interventionsinto health systems: a conceptual frameworkfor analysis Rifat Atun,1,* Thyra de Jongh,2 Federica Secci,3 Kelechi Ohiri4 and Olusoji Adeyi5 1Professor of International Health Management, Imperial College, London, UK, 2Researcher, Centre for Health Management, ImperialCollege London, UK, 3Doctoral Researcher, Centre for Health Management, Imperial College London, UK, 4Health Specialist, HumanDevelopment Network, World Bank, Washington, DC, USA and 5Coordinator of Public Health Programs, Human Development Network,World Bank, Washington, DC, USA.
*Corresponding author. Imperial College Business School, Imperial College, London. E-mail: [email protected] The benefits of integrating programmes that emphasize specific interventionsinto health systems to improve health outcomes have been widely debated.
This debate has been driven by narrow binary considerations of integrated(horizontal) versus non-integrated (vertical) programmes, and characterized by polarization of views with protagonists for and against integration arguing therelative merits of each approach. The presence of both integrated and non-integrated programmes in many countries suggests benefits to each approach.
While the terms ‘vertical’ and ‘integrated’ are widely used, they each describe arange of phenomena. In practice the dichotomy between vertical and horizontal isnot rigid and the extent of verticality or integration varies between programmes.
However, systematic analysis of the relative merits of integration in variouscontexts and for different interventions is complicated as there is no commonlyaccepted definition of ‘integration’—a term loosely used to describe a variety oforganizational arrangements for a range of programmes in different settings.
We present an analytical framework which enables deconstruction of the termintegration into multiple facets, each corresponding to a critical health systemfunction.
Our conceptual framework builds on theoretical propositions and empiricalresearch in innovation studies, and in particular adoption and diffusion ofinnovations within health systems, and builds on our own earlier empiricalresearch. It brings together the critical elements that affect adoption, diffusionand assimilation of a health intervention, and in doing so enables systematicand holistic exploration of the extent to which different interventions areintegrated in varied settings and the reasons for the variation. The conceptualframework and the analytical approach we propose are intended to facilitateanalysis in evaluative and formative studies of—and policies on—integration,for use in systematically comparing and contrasting health interventions in acountry or in different settings to generate meaningful evidence to inform policy.
CONCEPTUAL FRAMEWORK ON INTEGRATION OF INTERVENTIONS Systematic analysis of the relative merits of integration in various contexts and for different interventions iscomplicated as there is no commonly accepted definition of ‘integration’.
The analytical framework presented enables the term integration to be deconstructed into multiple facets, eachcorresponding to a critical health system function.
The conceptual framework can be used to analyse and map for different health programmes the nature and extent ofintegration in different settings, along with the factors that influence the integration process.
We developed the proposed framework because of its poten- tial relevance and applicability to real-life problems at the A longstanding debate on health systems organization relates country level. We visualize a health system as a complex adap- to the benefits of integrating programmes that emphasize tive system embedded within a broad context comprising a specific interventions into health systems to increase access set of interacting critical functions that include governance, and improve health outcomes. This debate, long characterized financing, planning, service delivery, monitoring and evalua- by polarization of views with protagonists for and against tion, and which are designed to achieve a set of objectives and integration arguing the relative merits of each approach, has goals (Atun and Menabde 2008). The reader is encouraged to been rekindled recently due to substantial rises in externally explore other frameworks (World Health Organization 2000; funded programmes for health interventions and health system World Bank 2004) and health system approaches developed by strengthening (Walsh and Warren 1979; Warren 1988; Wisner others (Roberts et al. 2004) which have informed our frame- 1988; Cueto 2004; Magnussen et al. 2004; World Bank and work but which are not appropriate for exploration of how health interventions are integrated into health systems func- This debate, which has been driven by narrow binary consid- tions. Our framework allows for consistent exploration of erations of integrated versus non-integrated programmes, integration in a holistic manner for each critical health system has also developed an ever-expanding lexicon of its own. For function, which we define, and the factors that influence the example, targeted programmes that emphasize specific inter- ventions are also called ‘vertical’, ‘categorical’, ‘stand-alone’ or In our model, health interventions are defined as complex ‘free-standing’ programmes, while programmes whose elements innovations, and ‘integration’ is explored using a diffusion of are integrated into health systems are also known as ‘horizontal innovation lens. The conceptual framework and the analytical approach presented in this paper are not intended to serve as approaches’. This abundant vocabulary has been further the only framework or approach applicable to the question enriched by the addition of terms such as ‘diagonal’ or ‘oblique’ stated above. Indeed, the authors recognize limitations of any to describe approaches that are not considered to be purely framework or normative approaches to complex issues in global vertical or fully integrated (Atun et al. 2008).
health that are not fully understood and are influenced by a The presence of both integrated and non-integrated pro- heterogeneous set of problems and interventions aimed at grammes in many countries suggests benefits to each approach.
addressing these in varied contexts.
However, the relative merits of integration in various contextsand for different interventions have not been systematicallyanalysed and documented. In practice, such an analysis iscomplicated as there is no commonly accepted definition of ‘integration’—a term loosely used to describe a variety of organizational arrangements for a range of programmes indifferent settings. Further, as the problem being addressed, the nature and extent of integration of interventions and outcomes We examine how health interventions are integrated into measured vary, there are methodological challenges to compar- health systems. Drawing on previous research methodologies ing various interventions in different settings. There is, hence, and approaches used to assess interventions and health systems a need to better define what is meant by integration and (Atun et al. 2004; Coker et al. 2004b) and perspectives from deconstruct it in a way that adequately captures various means organizational behaviour, strategy and innovation studies, we by which targeted health interventions are integrated into consider both the theoretical constructs and empirical evidence of adoption and assimilation of such interventions (Baldridge In this paper we present an analytical approach that enables and Burnham 1975; Downs and Mohr 1976; Tornatzky and us to define integration in relation to critical health system Klein 1982; Damanpour 1987; Meyer and Goes 1988; Rogers functions. We also describe a conceptual framework that can be 1995; van de Ven et al. 1999), specifically within health systems used to analyse and map for different health programmes the (Coleman et al. 1966; Kaluzny et al. 1974; Kimberly and nature and extent of integration in different settings, along Evanisko 1981; Greenhalgh et al. 2004; Atun et al. 2006; Atun with the factors that influence the integration process.
In this framework, we define integration as the extent, Broad Context
pattern, and rate of adoption and eventual assimilationof health interventions into each of the critical functions ofa health system (Atun and Menabde 2008), which include,inter Health System Characteristics
(iv) service delivery, (v) monitoring and evaluation (M&E),and (vi) demand generation. An ‘intervention’ in this contextrefers to combinations of technologies (e.g. vaccines, drugs), Adoption
modifications in processes related to decision making, planning,and service delivery.
We view a health intervention as an innovation, comprising new ideas, practices, objects or institutional arrangementsperceived as novel by an individual or a unit of adoption(Rogers 2003), while recognizing that in some cases theinterventions which have previously been implemented in small scale are scaled up and increased in intensity. In such Broad Context
instances, the ‘newness’ relates less to the technical element of Figure 1 Conceptual framework for analysing integration of targeted the intervention itself but to the organizational changes, new health interventions into health systems.
financing schemes and novel processes that accompany scalingup, intensification, integration and eventual assimilation of theintervention into the health system.
Empirical evidence suggests that adoption and diffusion of Greenhalgh 2001; Begun et al. 2003; Tan et al. 2005) that innovations in health systems is influenced by the nature and change and adapt in response to endogenous and exogenous complexity of the innovation (Plsek and Greenhalgh 2001; actions, disturbances or triggers. As with other dynamic Denis et al. 2002; Coker et al. 2004a; Atun et al. 2007), how it is complex systems, health systems comprise interacting feedback perceived by the adopters (Foy et al. 2002), contextual loops and non-linear relationships. In such systems the effects circumstances (Pettigrew et al. 1992; Coker et al. 2003; Atun of decisions are separated in time and space, hence, the et al. 2006), and health system factors (Atun et al. 2005b,c).
consequences of actions involving one or more elements of thesystem may not be immediately visible or accurately predict- Further, adoption and diffusion of these innovations are able. These relationships extend beyond the health system and influenced by the prevailing cultural norms, beliefs and values are intricately linked to the context within which the system is of the key actors and institutions within the adoption system embedded. Perturbations in the context influence system (Atun et al. 2005a)—in particular professional groups (Ferlie elements and changes in system elements affect the context.
et al. 2005) and opinion leaders (Locock et al. 2001; Fitzgerald Further, each intervention is internalized within a distinctive et al. 2002), social networks (West et al. 1999), systems and adoption system comprising multiple agents (individuals and structures that enable learning within an organization (Shortell organizations that operate within a set of cultural norms and et al. 1998)—and the absorptive capacity for new knowledge values) that act in ways that are not easily predictable. The within adopting organizations (Barnsley et al. 1998; Ferlie actions of these agents are interconnected; action by one agent changes the context for other agents. The interaction of the Drawing on relevant empirical evidence and theoretical innovation and the adoption system with the context influences propositions, we propose that the adoption and diffusion the responsiveness of the context, which, in turn, influences the of new health interventions and the extent to which they adoption and assimilation of the innovation in the health are integrated into critical health system functions will be system. These dynamic interactions are non-linear, and can influenced by the nature of the problem being addressed, the lead to unpredictable system responses with unintended intervention, the adoption system, the health system character- consequences (Atun and Menabde 2008).
istics, and the broad context. We build on this proposition todevelop a conceptual framework comprising five constituentsthat interact to collectively influence the extent, pattern and rate of adoption of an intervention within a health system, The characteristics of the problem will influence the rate at namely: the nature of the problem, the intervention, the which an intervention designed to address it is integrated into adoption system, the health system characteristics, and the the general health system. For example, the social narrative context within which innovation diffusion occurs. Our frame- around the problem, urgency and the scale of the socio- work enables analysis of the interactions and interconnections economic burden due to the problem will influence the between these elements, allowing a systematic and holistic perceived necessity of a robust response and the speed with analysis of adoption and diffusion of health interventions in which an intervention is integrated into the general health general. We discuss in more detail below the framework, which system. At times a rapid response may necessitate speedy introduction of an intervention with limited integration, followed by gradual assimilation as the problem is better CONCEPTUAL FRAMEWORK ON INTEGRATION OF INTERVENTIONS As discussed earlier, we define an ‘intervention’ as combina-tions of technologies, inputs into service delivery, organizational changes and modifications in processes related to decision making, planning, and service delivery, as well as scaling up ofinterventions previously implemented in small scale using novelprocesses. These interventions are introduced into health systems as innovations, comprising new ideas, practices, objects Perceived attributes of innovations, such as ‘relative advan- tage’, ‘compatibility’, ‘trialability’, ‘observability’ and ‘com- plexity’ influence the speed and extent of their integration(Rogers 1995). Less complex interventions more readily lendthemselves to standardization and replication than complex interventions. Consequently, they are more readily scaleable Figure 2 Intervention complexity: episodes of care and number of than interventions of greater complexity that require greater customization to meet the needs of the specific client groups indifferent contexts. However, whatever the perceived benefits,trialability, compatibility, observability or the level of complex- ity, new interventions are viewed with caution or circumspec-tion by multiple potential adopters, affecting the extent, patternand rate of their adoption.
Health interventions comprise multiple elements and facets— including technological, organizational and processual inno- vations. Their adoption depends on a range of users and they affect a variety of stakeholders. As such, they range in complexity depending on the number of elements and facetsto the intervention, temporal considerations in terms of cause and effect, and the stakeholders involved. In turn, the extent of complexity influences the compatibility of the intervention withthe existing system, its trialability, and hence more rapidrealization and observation of benefits (or adverse effects).
Therefore, health interventions could usefully be grouped usingintervention complexity as a dimension.
Figure 3 Intervention complexity: levels of care and number of For example, vaccination for childhood illnesses involves use stakeholders involved in delivery of the intervention.
of a new technology in a selected client group (who can bereadily identified). Typically, the intervention is deliveredby one or more health professionals at a single occasion or at Often, invermectin is administered as a mass treatment a limited number of occasions at regular intervals. Hence, it is more readily ‘trialable’, ‘observable’, its compatibility As compared with onchocerciasis or lymphatic filariasis, with the existing system more readily apparent, as are the perceived benefits (a child immunized) or adverse effects (Figure 4) as they usually involve multiple novel technologies (reaction to the vaccine). In contrast, integrated maternal and (diagnostic tools to determine infection levels to start treatment child health programmes involve multiple interrelated and and to monitor effect and side effects of drugs used, new interdependent interventions grouped together, delivered over antiretroviral treatments for HIV/AIDS and medications for a period of time at different levels of the health system to a treating co-infections), processes relating to introduction of range of stakeholders by a multidisciplinary group of health treatment guidelines, multiple workers (e.g. outreach workers, workers (Figures 2 and 3). As such, an integrated maternal doctors, nurses, social workers, peers, and families) and groups (civil society, communities affected by HIV/AIDS, media, human rights organizations) working at different levels across Intervention complexity is also determined by the number several sectors (e.g. health, education, law enforcement and and nature of technologies used to address a problem, and the penitentiary systems) for various groups, some of which are degree of user engagement needed to achieve improved difficult to reach (e.g. commercial sex workers and injecting outcomes or risk reduction. For example, interventions to drug users). The scope of interventions for these groups is wide, address onchocerciasis (river blindness) or lymphatic filariasis ranging from harm reduction programmes that combine (elephantiasis) typically use a single drug, ivermectin, adminis- technological and behavioural interventions, to elaborate care tered once annually (and in the case of lymphatic filariasis in regimes applied over many years often in resource-poor combination with albendazole) to infected or at-risk popula- settings. Success of these interventions requires strong stake- tions in endemic areas, in collaboration with local communities.
holder involvement and user engagement.
Hence, in practice, the adoption process may not be linear oroccur in discrete steps.
Integration can occur at different levels of the health system—local, district, regional or national depending on theprevailing governance arrangements—in relation to criticalhealth system functions, which include, inter alia, governance, financing, planning, service delivery, M&E, and demand generation. We briefly discuss below what integration intocritical health systems functions means in practice.
Integration of an intervention into broader health system governance functions will involve alignment with existingregulatory mechanisms, creation of unified accountabilityframeworks, integration of reporting, and establishment of a common performance management system. Integration into financing functions can occur in various ways, for examplepooling of finances for the intervention into the existing national/local programme budgets, into health sector funds through a ‘sector wide approach’ or a ‘common basket’ or In our framework, the adoption system refers to key actors directly into the government/ministry of health budget through and institutions in the health system, but also beyond this in ‘budget support’. Health interventions can also be integrated the broad context, with varied interests, values and power into health system planning functions at local and national distribution in relation to the health intervention concerned.
levels, especially in relation to needs assessment, priority These actors include policy makers, managers, health care setting, capacity planning, and resource allocation. Integration purchasers, health workers (physicians, nurses, professions of monitoring and evaluation often underpins the integration allied to medicine), patients, professional associations, patient with planning and governance functions, and would include groups, religious authorities, affected communities, faith-based use of shared indicators and establishment of integrated data entities, and civil society organizations.
collection, recording, analysis and reporting systems.
Each of these stakeholders have differing perceptions of Demand generation is a critically important but frequently the benefits and risks of an intervention, and consequently overlooked health system function, as many programmes in occupy disparate positions and roles in the adoption process health systems emphasize the supply-side interventions. Inte- (Greenwood et al. 2002; Atun et al. 2005b). The nature of these gration of demand generation activities could involve use of perceived benefits and the incentives they create vary for each joint systems for financial incentives (for example conditional group. Often these are non-monetary or economic incentives cash transfers, health insurance), or joined-up approaches for such as those relating to health/human rights, equity, power individual- and population-level health education and promo- and normative views on a value position (such as libertarian views which stress the individual versus more communitarianapproaches that espouse the community). These perceptions areshaped by a number of factors, for example the way by which intervention ‘benefits’ are communicated and how the inter- In our framework we define the broad context as the interplay vention ‘conforms’ to existing institutions, prevailing beliefs of the demographic, economic, political, legal, ecological, socio- and value systems, inherent incentive systems—especially the cultural (including historical legacies), and technological factors extent to which the intervention aligns incentives for users, in the environment in which the foregoing considerations (the provider and managerial agencies—and the perceived ‘legiti- problem, intervention, health system characteristics and the macy’ of the intervention (in particular cognitive, technical, adoption system) are considered (Atun and Menabde 2008).
economic and normative legitimacy) (DiMaggio and Powell This context matters as the adoption and assimilation of a 1983; Suchman 1995). Collectively, the perceptions and posi- health intervention into a health system, and its sustainability, tions of these actors determine the ‘receptivity’ of the adoption will be dependent on a number of contextual factors.
Critical events (such as regime change or a catastrophe) and technological change (such as a new diagnostic tool, a newand affordable drug, or a new prevention mechanism) provide opportunities for more rapid adoption and assimilation of Health innovations are gradually adopted and assimilated interventions into health systems. Opportunities are also into health systems as a result of a cumulative and unpredict- created when demonstrable synergies and benefits can be able translation process. Often, the adoption involves not just achieved by integration (such as nutritional interventions with changes in service content but regulatory, organizational, immunization, joint programmes for neglected tropical diseases, financial, clinical and relational changes involving multiple tuberculosis and HIV/AIDS and so on). However, even when stakeholders. These interactions shape and transform the evidence on the benefits of an intervention exists (providing innovation to ensure alignment of its elements with critical technical and economic legitimacy), the prevailing political health system functions in line with stakeholder expectations.
economy and socio-cultural norms (affecting cognitive and CONCEPTUAL FRAMEWORK ON INTEGRATION OF INTERVENTIONS normative legitimacy) will influence the desirability for adop- The analysis can provide a detailed account of the purpose tion and assimilation of the intervention.
of the integration (as perceived by key actors or as stated in In some contexts, integration will be hindered by factors that key documents), organizations, decisions and choices made, influence the health system but extend beyond it; for example, and the policy and programmatic trade-offs considered. The fiduciary requirements imposed on donor agencies by their narrative of the analysis summarizes the findings from the governing structures which require them to ‘ring fence’ funding interviews with key actors on their perception of the ‘relative streams or be able to attribute results to their investments.
success’, or lack thereof, of integration, and the impacts and Another example is the complexity of fiscal relationships unintended consequences on each critical health system among levels of government, as between central, provincial function as perceived by them. Depending on data availability, and local governments in some federal systems. Lower tiers of this narrative captures secondary data to triangulate and government might have no incentives to implement centrally validate findings from interviews of key actors. The analysis funded interventions unless such funds were earmarked by and can reveal the reasons for integration or non-integration and from the central level. We recognize these context-specific enables the policy makers to develop locally identified options constraints and do not consider them to be inherently bad or and preferences for future action that arose from the case good. Finally, the severity of the problem coupled to frailty of study. For example, the reasons for non-integration of monitor- the political and economic situation may call for expediency, ing and evaluation may be due to donor conditionality that while fiscal space considerations, which introduce spending requires the country to report on a set of indicators that lie ceilings on the health system, may impose constraints on beyond the core set used by the ministry of health. Similarly, integration as it may not be possible to appoint new staff to be financing of the health intervention in question may not be on the regular payroll in the government-financed element of integrated because the existing local systems are not robust enough to capture resource flows (which with appropriateinvestment could be addressed) or due to requirement of thedonor not to pool funds (as is the case with some major donors, and in which case in spite of the obvious benefits in some casesmay be difficult to achieve).
We anticipate that the use of this framework at the country To the policy maker and the practitioner, a framework is only level will lead to its refinement over time, and its use to develop as good as the extent to which it is applicable to real-life a database of health systems that could be compared and problems. This framework can be used when undertaking contrasted in terms of their adoption of interventions, integra- literature reviews, programme reviews, detailed country case tion of these interventions into health system functions over studies to explore how novel health interventions and health time, and the extent to which the external or donor envi- systems interact, or programme planning at the national or ronment played a role, among other factors, in this process.
sub-national levels. In relation to case studies, the conceptual A comparative analysis of decision space in the decentralization framework can be used to develop tools to capture data of health systems is an example of such multi-country studies including a topic guide for in-depth interviews with key informants. The data tools and the topic guide are customizedto ensure relevance to the context studied. The framework canbe used along two dimensions: (i) diagnostic, which empha- sizes the past and current situations, and (ii) formative,focusing on the future.
While the terms ‘vertical’ and ‘integrated’ are widely used, they The diagnostic exercise can be used for detailed mapping of each describe a range of phenomena. In practice the dichotomy the health intervention, and in particular the purpose, extent and between vertical and horizontal is not rigid and the extent nature of integration of the health intervention(s) under study of verticality or integration varies between programmes. We into critical health system functions, with classification of the present an analytical framework which enables deconstruction extent and nature of integration of the priority intervention(s) of the term integration into multiple facets, each corresponding into each health system function as fully integrated, partially to a critical health system function.
integrated, not integrated, or unknown. By examining each The conceptual framework and the analytical approach we critical health system function in this manner, the framework propose are intended to facilitate analysis in evaluative and enables both the macro-analysis of integration (for the overall formative studies of—and policies on—integration, but not as health system) and the micro-analysis of integration (for a prescription. The framework can be used to systematically example, for only one function). While it would help in each compare and contrast health interventions in a country or in context to describe what a fully integrated health system might different settings to generate meaningful evidence to inform look like, the framework is agnostic about whether or not a particular system should be fully integrated; that, in our view, Adoption, diffusion and eventual assimilation of a health is a matter for the policy makers to decide in each context.
intervention in a health system necessarily involve their Instead, the analysis can be used for a detailed exploration of translation and transformation to ensure alignment of inter- why and how the health intervention is integrated into various vention elements with critical health system functions. The health system functions, and how the extent and nature of speed and extent of this integration will vary—in part, deter- integration is influenced by factors relating to the intervention, mined by the intervention complexity, the health system adoption system, health system and the context.
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