As put forth by the Astana Declaration, all individuals should enjoy the right to health - defined as a state of physical, mental, and social well being. In order to address the comprehensive needs of an individual - including the economic, social, and environmental determinants of health - services must be wide in scope and integrated across and beyond the health sector. 18 19 20 To promote universal access to high-quality comprehensive services, health systems should strive to facilitate coordination efforts that both enhance the capacity and infrastructure of primary care (such as through integrated health service delivery and multisectoral action discussed below) and empower individuals and communities to participate in health promotion. 18
Integrated health services delivery
Integrated health service delivery is an approach to strengthening people-centered health systems through the promotion of comprehensive, coordinated services across the continuum of care. 21 22 Integrated care models serve to adapt to the complex needs of individuals, their families and communities to promote the equitable delivery of services. 23 24 To meet the complex needs of people and strengthen integrated health service delivery, integrated care models deliver care through community-based coordinated multidisciplinary teams across sectors and levels of care. 8 21 25
Integrated models that offer a more comprehensive set of skills and services at the frontline (including diagnostic, pharmaceutical, behavioral, rehabilitative services) can help to increase the efficiency and timeliness of primary health care 16 26 27 Integrated models help to promote continuity and coordination through the use of referral networks and strong health information technology systems that promote communication channels among levels of care. 28 29 30 More information on different models and approaches to integrated care can be found here and in the WHO Framework on Integrated, People-Centered Services.
In communities where it is difficult to access routine and reliable care, integrated care models that deliver comprehensive care during single point of care interactions may be particularly useful, especially for patients with complex conditions. Standardized and simplified guidelines and training materials that allow for task-shifting and referral networks between frontline workers and facilities help to equip multidisciplinary care teams with the competencies to provide higher quality comprehensive and coordinated care to low-resource communities that face limited opportunities for prevention, treatment, and management of diseases. 31 The WHO Integrated Management of Adolescent and Adult Illness modules and the WHO Package on Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Resource Settings offer important implementation plans for integrated care strategies (with emphasis on chronic diseases) with lessons on providing equitable, efficient, and cost-effective care through the provision of comprehensive services. Additionally, users can learn about integrated care in the case study about the Integrated Care Cascade in Malawi, included in the What Others Have Done section of comprehensiveness.
Across all integrated care delivery models, it is imperative to engage strategies that are cost-effective and efficient in the use human, financial, and physical resources (especially for the discovery and management on complex conditions) and coordinated with the broader health system.
Proactive comprehensive care: integrating public health and primary care
One such model to promote comprehensive person-centered care integrates public health into primary care. 32 Leveraging the strengths of both primary care and public health holds the potential to increase efficiency gains and opportunities to combine available resources to a mutual benefit. 33 The WHO Technical Series on Primary Care outlines six models to achieve integration between public health and primary care. These models are adaptable to different health systems and can be implemented individually or in combination, listed below:
- Public health professionals integrated into primary care
- Public health services and primary care providers working together
- Comprehensive and proactive benefit packages that include public health
- Primary care services within public health settings
- Building public health incentives into primary care
- Multidisciplinary training of primary care staff in public health
While not all of the five core functions of public health (surveillance, monitoring preparedness for response, health protection, health promotion, and disease prevention) can be fully integrated into primary care, there are considerable gains to be made for primary care to take on a more proactive role in contributing to public health interventions, especially in the realms of health promotion and disease prevention. 34
As discussed in first-contact accessibility, there is a substantial global shortage of skilled health workers appropriately trained to deliver comprehensive care. 41 A workforce competent in comprehensive PHC (preventive, promotive, chronic, behavioral, and rehabilitative) must exist and be appropriately distributed both in quantity and cadre as a precondition for ensuring universal access to high quality and comprehensive services. Presence of poorly trained staff in some cases may be worse than no staff at all. When a patient of any type shows up to a PHC facility, there needs to be: a facility with minimum equipment, methods, and medications to diagnose and treat a wide range of problem (especially those most common the local community), staff who are skilled at diagnosing and managing a broad spectrum of problems (including patients with multiple problems i.e. multi-morbidities) and providing preventive services, and a referral system that can effectively transfer care or solicit expert support (i.e. specialists) in managing the small number of problems that fall out of scope of what primary care can manage. Strategies for strengthening the health workforce will be discussed in more detail in the Workforce module. The case study on Malawi’s Integrated Care Cascade in the what others have done section of comprehensiveness showcases one innovative approach to addressing the complex burden of disease in the primary care setting through integrated care models and diverse care teams. Stakeholders can find more information on looking to skill-mix (assembling a diverse team of providers) as a potential solution to overcoming workforce shortages and providing high-quality care in the Team-Based Care Organization module and the World Health Organization’s Global strategy on human resources for health: workforce 2030 report.
Multisectoral engagement and social accountability
As a part of building comprehensive primary care systems, it is essential for primary care services to meet the complex needs and demands of the entire population. Intersectoral action in health promotes comprehensiveness by engaging other services and sectors, directly and indirectly, involved in the health of people and communities across the continuum of sectors engaged in primary health care delivery. (9,35–37) Multisectoral and intersectoral collaboration help to contribute to more comprehensive policies by taking on a systematic approach to the promotion of health and well-being a priority across sectors. 37 Stakeholders can access more information on the design of multi and intersectoral policies for overall health and well-being and sustainable development in the WHO Health in All Policies Framework. The accompanying Health in all Policies Training manual offers comprehensive training materials to facilitate the engagement and implementation of the HiAP approach across sectors.
To foster productive partnerships and actionable policies, strong political-commitment and mechanisms for social accountability must be in place. 38 Encouraging broader social participation in the policy process (such as citizen groups and media platforms) helps to strengthen accountability across sectors and forge collaborative partnerships for comprehensive initiatives. 37 More information on multi and intersectoral engagement and social accountability can be found in the WHO report on multi-sectoral and intersectoral action for health and well-being for all and in the Social Accountability module.