Health systems transformation: integrated care at the frontline
As put forth by the WHO Framework on Integrated People-Centered Health Services, care should be coordinated around the comprehensive needs of people, taking into account the political, economic, social, and environmental determinants of health. Reoriented care coordination with PHC as the foundation requires a shift toward a community-based and collaborative model of care that is designed to support the complex needs of the patient at the frontline. The frontline comprises the primary health care system and network of frontline health workers and institutions that serve as a patient’s first-contact points with the health system. It also includes channels outside of the formal health infrastructures that empower patients and communities in the co-production of their health and well-being, such as social workers and psychologists. 18 In a PHC-oriented system, the person is at the center of the system, with the majority of their needs met at the frontline. Intersectoral collaborations and networks with the broader health system support PHC in the effort to achieve the best possible health outcomes for a person 22122 Two-way refferals and robust communication networks with the broader health system and/or other sectors 18 aid in appropriate treatment and continuity of care. 19 Two-way referral systems is discussed in greater depth in what policies, strategies, and infrastructure should be in place to support coordinated care: referral management systems.
Integration helps to promote coordination in service of comprehensiveness by bridging and aligning the skills, services, and resources necessary to meet the complex needs and demands of patients. Integrated health services are managed and delivered so that patients receive a comprehensive set of services (promotive, disease-management, preventative, behavioral, rehabilitative) throughout their life course, coordinated across different levels of care and care settings within and beyond the health sector. 14 To promote integrated service delivery at the frontline, coordination mechanisms should promote linkages between PHC and other sectors either directly involved in the delivery of primary health care, such as private primary care providers, or partnerships with other non-health sectors which harness the potential to increase the capacity of the primary care system to meet the needs and demands of people and communities. In addition, effective coordination mechanisms promote intersectoral action at the community level to address the social determinants of health and ensure the appropriate use of resources, especially in poor-resource settings. 20 The WHO Technical Series Document on Integrating Health Services outlines four avenues for integration with primary care as the hub for service delivery below:
- Integrating primary care and public health: discussed in greater depth in Comprehensiveness: proactive comprehensive care
- Integrating primary, secondary and tertiary care: discussed in greater depth in the sections below on vertical and horizontal integration, with case studies in Coordination: What others have done
- Integrating dedicated health initiatives into primary care: discussed in greater depth in Primary Health Care Policies
- Integrating sectors: discussed in greater depth in below in coordinating services within and across sectors and private sector participation and engagement
Integration requires the sustained support of communities and stakeholders at the local, regional, and national level. Steps to integration are country-specific and will depend on the capacity of the system (including the availability of resources and political will) to support integrated service delivery. 21 To enable multisectoral collaboration, coordination efforts must be of mutual benefit to all involved sectors. Conflicting interests, competition for limited resources, and a lack of collaborative thinking among actors challenge the creation and sustainability of policies and initiatives that promote coordination. 2223
To improve the delivery of care through coordination mechanisms, the WHO Framework on Integrated People-Centered Health Services outlines a range of strategies, policy options, and interventions designed to integrate care providers within and across levels of care, develop referral systems and care networks, and create multi and intersectoral linkages. More information on optimizing care coordination to support the WHO Framework on Integrated People-Centered Health Services can be found in the WHO practice brief on continuity and coordination of care. Additional strategies for multisectoral and intersectoral collaboration are accessible in the WHO report on multi and intersectoral action for improved health and well-being for all.
Coordinating across levels of care through vertical and horizontal integration
To promote better coordination of care, health systems can adopt horizontal and vertical integration strategies. Comprehensive integration achieves a balance of both horizontal and vertical integration. 24
Horizontal integration involves collaboration across sectors to promote the delivery of comprehensive primary care. By creating linkages within and beyond the health sector, horizontal integration helps to optimize the use of resources and better meet the comprehensive needs of populations. 14 In this way, coordinating proactive outreach and service delivery efforts can help to promote the more efficient use and management of a comprehensive set of services. 25 More information on multi-sectoral and intersectoral action for health is found in the next subheading, coordinating services within and across sectors.
Vertical integration involves redefining the role and interactions among primary, secondary, and tertiary facilities to promote coordination and service delivery across levels of care. Most initiatives in vertical integration are conceptualized in terms of referral systems. 26 A variety of bureaucratic obstacles challenge referral systems including provider divisions, differing priorities among levels of care, and distinct administrative and budgeting processes. 26 To promote primary care as the first point of contact, referral systems should align with empanelment and gatekeeping structures in place, and promote bidirectional referrals. Strategies to strengthen vertical integration to ensure coordination and continuity can be categorized along three dimensions: 25
- Redefining facility roles within a vertically integrated network: Redefining the roles of actors will require collaboration and cooperation among health facilities at different levels of the health care system. This process will help to define the range of services facilities will provide and how facilities will support each other across levels of care through supervision mechanisms, technical assistance, and partnerships (such as accountable care organizations). Clearly defined contracts, payment, and incentive structures should be in place.
- Strengthen relationships among providers: Skill building and technical training opportunities may help to improve the quality of care and competency of providers in facilities, establish interfacility relationships, and promote communication networks across levels of care.
- Develop formalized facility networks based on the 3-in-1 principle: The 3-in-1 principle redefines the role and interactions among facilities toward a common goal based on “one-system-one population-one pot of resources”. Highly developed networks offer a broad continuum of care across all service lines, enabled through information technology (eHealth) tools.
Vertical integration is resource-intensive and contingent on the operations of a coordinated system across levels of care, making it difficult to facilitate in low-resource settings lacking strong referral networks and information systems. Additional information on financial, institutional, and logistical barriers to vertical integration and ways forward are available via the JLN Vertical Integration Virtual Learning Exchange.
Creating effective and efficient horizontal and vertical integration networks is resource and time intensive. Achieving coordination will require a long-term, system-wide commitment to collaboration across and within levels of care and an investment in resources (including strong information technology networks and workforce training programs) to create and sustain this system. More information on strengthening health systems through coordination can be found in the WHO Framework for Action Toward Coordinated/Integrated Health Services Delivery and the World Bank report on Health Reform in China More information on coordination activities and broad approaches to improve the delivery of care can be accessed in the Care Coordination Measures Atlas from the Agency for Healthcare Research and Quality.
Private sector participation and engagement
In health care systems with a large proportion of primary care delivery in the private sector, it is essential to ensure that coordination mechanisms are also linked with the private sector to promote continuity of care. However, there are many system-wide challenges and considerations to effective private-sector engagement. Stakeholders should consider the intention and benefit of the partnership, such as whether private services should be complementary or supplementary to public services, the regulatory capacity to oversee private sector development (at local, regional, and national level), and given the for-profit nature of private enterprises, the challenge of attracting private sector expansion in remote and underserved areas. 25 Central policy directives that promote greater private-public collaboration require robust regulatory and supervisory mechanisms, a shared vision for equitable high-quality primary care delivery, and incentives that level the playing field for the entry of the private sector (such as insurance reimbursements equal to public facilities, tax-policies) in both rural and urban areas. 25
The Joint Learning Network for Universal Coverage has identified five steps to private-sector engagement including: preparing for dialogue with stakeholders by conducting stakeholder analysis, understanding and detailing rationales for engaging the private sector in PHC, actively listening to the private sector, finding areas of common ground and first steps for collaboration and trust, and establishing a regular consultative process with joint agenda setting. 27 Additional information on engaging the private sector and possible forms of partnership including a step-by-step guide to mapping private sector providers from the Joint Learning Network can be accessed here and in the WHO Technical Series Document on the Private Sector, Universal Health Coverage and Primary Care.
Improve professional working conditions and skills
As with any intervention or system that requires behavior change on the part of the provider, it is important for health systems to offer professional development opportunities and a motivating work environment. 15 Unsatisfactory working conditions (such as temporary and/or part-time contracts, insufficient time, inadequate remuneration) and limited professional training opportunities hinder coordination mechanisms by damaging provider motivation and attitudes toward collaboration. 1617 More information on building professional development offerings and fostering positive work environments can be accessed in provider motivation mechanisms, provider competence, team-based care organization, and facility management capability and leadership.