LESSONS LEARNT FROM THE CASE STUDIES ON INTEGRATED HEALTH SERVICES DELIVERY NETWORKS AND VERTICAL PROGRAMMES

1. LESSONS LEARNT FROM THE CASE STUDIES ON INTEGRATED HEALTH SERVICES DELIVERY NETWORKS AND VERTICAL PROGRAMMES Edwin Vicente C. Bolastig, MD, MSc Consultant, PAHO/WHO 14th September 2010 Rovanel’s Resort, Tobago

2. 2 Presentations: Case Study on the Integration of HIV/AIDS Services in Trinidad and Tobago into Maternal, Newborn & Child Health Services, as well as Sexual and Reproductive Health Services, including Family Planning (focused on Tobago findings) Experiences and Lessons Learned from Case Studies in the Region of the Americas 2

3. Case Study on the Integration of HIV/AIDS Services in Trinidad and Tobago into Maternal, Newborn & Child Health Services, as well as Sexual and Reproductive Health Services, including Family Planning Edwin Bolastig, Yoko Laurence and Karen Pierre Funded by: Pan American Health Organization/ World Health Organization

4. OBJECTIVES OF CASE STUDY To contribute to the body of work on health services integration To determine: “how vertical programs and Global Health Initiatives have impacted on the health system, and affected segmentation/fragmentation” 4

5. TRINIDAD AND TOBAGO: Southernmost Caribbean country Independence 1962; Republic 1976 Parliamentary democracy Multi-ethnic population: 1.3M Oil and gas-based economy GNI per capita (09):US$ 17,884 10-year GDP growth(99-08): 7.7% Epidemiologic shift: CNCDs over 60% of deaths 5

6. CONTEXT First HIV case diagnosed in 1983 8th leading cause of death in 2004 STI-HIV co-infection prevalence rate: 42% (60% M ; 40% F) (Buensuceso, 2008) HIV/AIDS cause enjoys strong political support World Bank loan, EU grant, CARICOM PANCAP, government, private sector funding 6

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8. SEGMENTATION/FRAGMENTATION Decentralisation of health service delivery to RHAs with the exception of Vertical Programmes and Services Fragmented human resource management Dual employment system Information and medical records management largely manual Unstructured referral system 8

9. HIV INTEGRATION INITIATIVES Integration with Maternal and Child Health - PMTCT Integration with STI and Family Planning - VCT Integration with Population Programme - PITC Integration with Chronic Disease Care Tobago Health Promotion Clinic (THPC) Integration of Treatment with Prevention – San Fernando General Hospital Integration of Information Systems for HIV/AIDS TERIDA Project 9

10. Description of the Process of Integration of HIV/AIDS services in Trinidad and Tobago using PAHO’s Framework on Integrated Health Services Delivery Networks (IHSDN) 10

11. The covered population/territory is defined and there is broad knowledge of its health needs and preferences, which determine the services provided by the system. HIV Prevalence: 1.5% of Population (generalised epidemic) Perception that high-risk groups are well-defined but targeted prevention not happening In Tobago, youths targeted but not MSM or sex workers 11

12. 2. An extensive offer of health facilities and services, which include public health services, health promotion, disease prevention, timely diagnosis and treatment, rehabilitation, and palliative care, all under a single organizational umbrella. Tobago Health Promotion Clinic (THPC) – Dr Noel behaviour modification, social services, housing, religious/pastoral services, mental health, substance abuse, mobile services, nutrition, dental referral, etc. 12

13. A first level of care that acts as the de facto gateway to the system, integrates and coordinates health care, and meets most of the population’s health needs. Tobago Health Promotion Clinic (THPC) is the gateway into the system 13

14. 4. Specialist services delivered in the most appropriate place, preferably non-hospital settings. Pregnant women referred to THPC Baby treated at paediatric ward in TRH One (1) HIV specialist in Tobago for adults but none for paediatric care 14

15. 5. Coordination of care mechanisms exist throughout the entire continuum of services. A full and integrated coordination of care mechanism is compromised due to: A lack of feedback to and from TPHC Ineffective utilisation and training of personnel within organisations. 15

16. 6. Health care centered on the person, the family, and the community/territory. Health professionals from the health centres and THPC sometimes go out to the community to do testing via the Mobile Clinics at football games or all-fours clubs. THPC has a programme that provides support to discordant couples, allowing these couples to have children who eventually turn out to be negative No prevention programme for at risk families 16

17. 7. A single, participatory governance system for the entire IDS. National Strategic Plan for HIV/AIDS is monitored by the NACC under the Office of the Prime Minister), while implementation of the Health Sector Plan is monitored by the Ministry of Health through HACU. In Tobago, THPC falls under the Tobago House of Assembly (THA); Tobago HIV/AIDS Coordinating Committee (THACC) serves as the link between NACC and THA 17

18. 8. Integrated management of administrative and clinical support systems. Disparate administrative and clinical support systems are not managed in an integrated manner At THPC, administrative and clinical support addressed by some administrative staff but everyone working at clinic can provide support services if necessary 18

19. 9. Sufficient, competent human resources, committed to the system. Human resources for the THPC are considered insufficient given the comprehensive nature of the clinic in terms of HIV and chronic disease treatment, which has caused the clinic to grow continuously since its inception. Only 16 of required staff of 27 19

20. 10. An integrated information system that links all members of the IDS. Figure 1: TERIDA – IT System Diagram Tobago not included in pilot project 20

21. 11. Adequate financing and financial incentives aligned with the goals of the system. 2 schools of thought in terms of adequacy of financing: There is enough funding for HIV/AIDS, the problem is effective utilization and despite huge investments, there is no reduction of HIV in the general population. Financing could never be enough: as progress is made in diagnosis and treatment, new techniques, equipment and drugs emerge in the market. 21

22. 12. Broad intersectoral action. Collaboration between THPC and support groups like TAS, OASIS and others THACC is known for engaging the community through the village councils in the implementation of HIV-related projects. Corporate sponsorships but discrimination happens in the workplace 22

23. EMERGING MODELS Three (3) Emerging Models of Integration: Standalone outpatient HIV/AIDS clinic integrated with chronic disease care (Tobago Health Promotion Clinic) Hospital-based HIV/AIDS testing and treatment centres – adult & paediatric (San Fernando General Hospital) Satellite network of multi-tiered hospital based and outpatient health facilities 23

24. MODEL 1 – Stand Alone 24

25. MODEL 2 – Hospital Based Testing and Treatment 25

26. MODEL 3 – Multi-tiered Satellite Network 26

27. FINANCING – Total TTD 253.5 million 27 3-fold increase in prevention targeted to general population Funding for PMTCT declined but remained a success Substantial increases in treatment due to ARV medications Programme mgt, coordination & eval’n increased Government expenditures exceeded commitments Private sector and int’l organisations played some role 3-fold increase in prevention targeted to general population Funding for PMTCT declined but remained a success Substantial increases in treatment due to ARV medications Programme mgt, coordination & eval’n increased Government expenditures exceeded commitments Private sector and int’l organisations played some role

28. BENEFITS Programmes – institutionalisation of PMTCT; integration of VCT with SRH; free ARVs Resources - high levels of funding for HIV/AIDS also used for MCH, STIs and FP Processes - shift from a programme approach to institutionalisation of interventions Intermediate products – build capacity of committed health personnel Outcomes – increased HIV testing among mothers; improved efficiency in some areas; community outreach 28

29. Strengthening of services as pre-requisite to integration vs. Integration as means to improve services TWO SCHOOLS OF THOUGHT ON INTEGRATION: 29 From all of the information gathered, two opposing schools of thought on the integration process were uncovered: 1- Integration should not happen unless individual vertical services are strengthened so that the strength of one programme is not “diluted” by the weaknesses in other services or programmes. 2- Integration will facilitate the process of strengthening the weaker services or programmes by building upon the strengths of the stronger services or programmes. From all of the information gathered, two opposing schools of thought on the integration process were uncovered: 1- Integration should not happen unless individual vertical services are strengthened so that the strength of one programme is not “diluted” by the weaknesses in other services or programmes. 2- Integration will facilitate the process of strengthening the weaker services or programmes by building upon the strengths of the stronger services or programmes.

30. LESSONS LEARNT Facilitating factors: Role of advocates and champions in the health system Perception of strong political support from government Health promotion (high risk groups and wider population) Service delivery decentralisation (RHAs) Increased resources for HIV/AIDS Expanded role of civil society – “knowledge broker” 30 including mass media campaigns targets both high-risk groups and the wider population Increasing role of RHAs in carrying out the decentralised mandate of delivering services closer to where their target populations are ? success of the rapid testing programme, particularly in the NWRHA The mobilisation of increased resources for HIV/AIDS in improving infrastructure conducive to the delivery of services The role of Civil Society expanded to include “knowledge-brokering” ? brokering information not only between patients and doctors, but also with a wider network of support systems including mass media campaigns targets both high-risk groups and the wider population Increasing role of RHAs in carrying out the decentralised mandate of delivering services closer to where their target populations are ? success of the rapid testing programme, particularly in the NWRHA The mobilisation of increased resources for HIV/AIDS in improving infrastructure conducive to the delivery of services The role of Civil Society expanded to include “knowledge-brokering” ? brokering information not only between patients and doctors, but also with a wider network of support systems

31. LESSONS LEARNT Hindering Factors: Structural and support services – inadequate infrastructure, human resource shortages, weak reporting and referral systems Socio-cultural – breach of confidentiality, S&D, territorialism, lack of accountability Policy and legal environment – lacks policy framework for zero tolerance to S&D, non-adherence to protocols/SOPs 31 Structural and support services: Inadequate infrastructure, human resource limitations in terms of skill and training for testing and counselling, and inadequate information technology and data capture systems Human resource underperformance, shortages, high turnover and inadequate training ? recurrent hindrance to integration Weak reporting systems result in double counting of cases and an inefficient use of resources. Insufficient follow-on services Support systems for HIV services that do not operate at full capacity Physical facilities, in terms of portability of patient records; ease of flow of services and patients; and geographic location, need improvement Socio-cultural: Concerns about breach of confidentiality due to unethical distribution of private information by health workers Insufficient client support of services and programmes Stigma and discrimination, domestic abuse, lack of accountability, a culture of tolerance for underperformance and ‘turfism’. Policy and legal environment: An absence of or a lack of adherence to protocols, guidelines, SOPs or other policy instruments e.g. mechanism needed to force the private sector to take-up the policy Anecdotal incidents of discrimination of PLWHA by their employers, forcing them to change jobs more often than non-HIV positive individuals or HIV positive individuals whose status is unknown. Structural and support services: Inadequate infrastructure, human resource limitations in terms of skill and training for testing and counselling, and inadequate information technology and data capture systems Human resource underperformance, shortages, high turnover and inadequate training ? recurrent hindrance to integration Weak reporting systems result in double counting of cases and an inefficient use of resources. Insufficient follow-on services Support systems for HIV services that do not operate at full capacity Physical facilities, in terms of portability of patient records; ease of flow of services and patients; and geographic location, need improvement Socio-cultural: Concerns about breach of confidentiality due to unethical distribution of private information by health workers Insufficient client support of services and programmes Stigma and discrimination, domestic abuse, lack of accountability, a culture of tolerance for underperformance and ‘turfism’. Policy and legal environment: An absence of or a lack of adherence to protocols, guidelines, SOPs or other policy instruments e.g. mechanism needed to force the private sector to take-up the policy Anecdotal incidents of discrimination of PLWHA by their employers, forcing them to change jobs more often than non-HIV positive individuals or HIV positive individuals whose status is unknown.

32. AREAS FOR IMPROVEMENT Socio-cultural Health workforce Service delivery Systems interventions Policy and legal environment 32

33. CONCLUSIONS Resources for HIV/AIDS supported integration of HIV services with other health programmes such as Maternal and Child Health GHIs did not seem to have undermined national planning and policy development process Integration process aligned with national priorities, along existing mechanisms for coordination 33

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35. Integration Initiatives in LAC

36. Summary of Case Studies Lima Workshop, 9 November 2009

37. FACILITATING FACTORS AND BARRIERS 37

38. FACILITATING FACTORS Political commitment and backing Availability of financial resources Leadership of health authorities and service managers Decentralization and flexibility of local management Alignment of financial and non-financial incentives Culture of collaboration and teamwork Active participation of stakeholders 38

39. STRUCTURAL BARRIERS Segmentation and weakness of health systems Reforms of the 1980s and 1990s: Privatization of insurance Differentiated service portfolios Provider competition Diversification and instability of labor regimes Regressive cost-recovery schemes 39

40. STRUCTURAL BARRIERS Powerful opposing Interest groups: Specialists and super-specialists Private insurers and social security Pharmaceutical industry, supply industry, etc. External financing modalities (Global Health Initiatives) 40

41. NON-STRUCTURAL BARRIERS Deficiencies in information, monitoring, and evaluation systems Management weaknesses 41

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43. Thank you! 43