WFOT: Comments on the “WHO GCM-WG 3.1 draft interim report” September 2016
These comments were provided by a WFOT international review team covering a total of ten high, middle and low income countries.
Overall comments:
This document is appropriate for all countries. The focus on integration and integrated care is appreciated, as is the focus on prevention and the promotion of people-centred primary health care and universal health coverage. It is a highly ambitious policy and while this is exciting, the practical implications at all levels are considerable, particularly for resource- poor countries. Overall, the policy addresses key considerations and the structure of the document potentially aids understanding and action, though opportunities exist to strengthen clarity and coherence, and there are some omissions that warrant articulation. Examples follow below. The explanation of ‘integrated care’ and ‘integration’ (page 2, paragraph 2) may be confusing for some audiences (e.g. both talk about ‘organising’). The Overarching Principles, draft Recommendations and Policy Options neglect to specify particular vulnerable groups (only referring to youth, families, communities and patients); people with disability, indigenous populations, and refugees are among those who should also be explicitly identified, not least because specific inclusion/integration strategies may be required as well as making the link with human rights, equity principles and other UN/WHO policies and conventions. The notion of presenting ‘policy options’ for each of the draft Recommendations is a positive one but in actuality the points listed are more ‘indicative/suggested strategies’ rather than ‘options’; furthermore, many are co-dependent and most are complex and, as has been identified, will require substantial resources (including expertise and funding). The Concept of Integration and the Overarching Principles promote the need for a ‘whole of government’/whole of community type of approach but the nine draft Recommendations don’t adequately reflect or incorporate this – they are MOH-centric, and while it is appreciated that Health sectors will take the lead, there is a need to strengthen reference to strategies for promoting/developing cross-sectoral collaboration and integration. This is especially the case, for example, for people with disability whose wellbeing tends to come under departments of social services/welfare.
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Grouping the draft Recommendations under two sub-headings (Governance/Upstream/vertical and Service Delivery/Downstream/Horizontal) is somewhat confusing. An introductory statement referring to these dimensions may be more valuable.
Health system stewardship and evidence informed policy making has a role to play in engaging relevant sectors for enhanced national multisectoral collaboration and coordination, enabling proper participation of communities, and ensuring institutional and financial mechanisms are fit for purpose. This WHO concept is not mentioned and perhaps should be.
This document is comprehensive with context-sensitive recommendations with respect to the prevention and control of noncommunicable diseases (NCDs).
One notable gap, from an occupational therapy perspective, was that this paper was essentially silent with respect to the special concerns of people with disabilities in preventing and managing NCDs. People with physical disabilities, cognitive impairments, and severe mental illness have significantly higher risk of contracting NCDs and of their NCDs being poorly managed or controlled. There are many significant barriers to NCD prevention and control in this population that warrant attention: Healthcare providers are often poorly trained in how to provide appropriate preventive care to this population. They may not even be aware of the need for, and potential benefits of, preventive care because of preconceived notions of this population's being destined to experience poor health, or that, given that they have a disability/impairment, it is 'too late' to prevent illness and there is no added benefit with respect to the health and quality of life of these persons to devoting resources to NCD prevention and control.
There are environmental barriers to accessing care, such as the physical accessibility of facilities and medical equipment.
Many of the sequelae of disabilities (such as limited movement) and medications used to treat symptoms of impairment or disability may themselves predispose this population to developing NCDs
People with disabilities are disproportionately poor and from underrepresented minority groups, and thus are subject to health disparities due to demographic characteristics in addition to the disparities related to having a disability - thus in a sense they are doubly disadvantaged with respect to NCD prevention and control. In addition to the above, given the emphasis throughout the document on access, equity, and local control of healthcare decision making, it is recommended that there is more discussion of health disparities related to sociodemographic variables. It is clear that special efforts are needed to counter these disparities. The focus on patient/family/community centered care, and attention to geographic equity of services, will go some way towards closing the gap with respect to health disparities but without devoting specific resources to marginalized communities, it is likely that their health will continue to lag behind those of more advantaged groups.
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Overall, providing the right care, for the right people, at the right place resonates with the ethics of occupational therapy and occupational justice - depending on the definition of the “right” people.
Occupational therapists can play a key role in alleviating the effects of NCDs on human beings to preserve the ability to achieve functional and independent life activities.
Service delivery most importantly should include occupational therapists. The strategies should be health oriented with occupational therapists in place where ever necessary in prevention, intervention, treatment, rehabilitation and integration of services, and the development and maintenance of a sustained workforce.
When governments consider leadership from the health sector, occupational therapists and occupational therapy models must be included. Occupational therapists are important to the success of NCD strategies and achievement of related goals. The inclusion of occupational therapy and occupational therapists is essential to teams and the health support system. Related expenditure must be addressed.
Assessment, diagnosis, treatment and functional rehabilitation will also require occupational therapists to play a key role in health care process.
There is a compelling need to develop built in systems and procedures to deliver policies/plans/services to the beneficiaries/stakeholders. Potential staff burnout and retention must be addressed in the total system.
In order to guarantee these changes will be made it is suggested that each country could provide a full report., containing data about the actual situation, tailored objectives and the actions that will accomplish the overall goals.
The recommendations could address the role of NGO's in promoting health and wellness to individuals and the community.
Examples of Occupational Therapy addressing the NCDs, Wellness Promotion, and related information:
WFOT Bulletin – The World Federation of Occupational Therapists (WFOT) Bulletin is the official publication of the WFOT. Its aim is to promote awareness and understanding of the WFOT and its activities and services, the development of the occupational therapy profession worldwide, and the international exchange of professional knowledge and experience. International articles relating to NCDs and occupational therapy are regularly included in the Bulletin. More information is available at http://www.wfot.org/Bulletin.aspx
Examples of publications relating to Occupational Therapy and NCDs include:
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Health Promotion in the Seychelles. http://www.health.gov.sc/index.php/2016/07/15/health- minister-opens-symposium-on-patient-centred-care/
Neufeld, P. & Kniepmann, K. (2001). Gateway to Wellness: An Occupational Therapy Collaboration with the National Multiple Sclerosis Society. OCCUPATIONAL THERAPY IN HEALTH CARE. Retreived from http://dx.doi.org/10.1080/J003v13n03_07 Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2016, September 2). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 1–19. doi.org/10.1177/1077558716666981https://doi.org/10.1177/1077558716666981 See more at: http://www.aota.org/Publications-News/AOTANews/2016/Occupational-Therapy- Reduces-Hospital-Readmissions.aspx#sthash.nUymgKYX.dpuf
Scott, A., (1999). Wellness Works: Community Service Health Promotion Groups Led by Occupational Therapy Students. American Journal of Occupational Therapy, November/December 1999, Vol. 53, 566-574. doi:10.5014/ajot.53.6.566
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The following WFOT Position Statements inform the occupational therapy perspective in the promotion of the inclusion of the prevention and control of noncommunicable diseases (NCDs).
WFOT Position Statements can be accessed from the WFOT website www.wfot.org >Resource Centre > filter resources by category: Position Statements
Activities of Daily Living (2012) Client-centredness in Occupational Therapy (2010) Community Based Rehabilitation (2004) Consumer Interface with Occupational Therapy (2010) Diversity and Culture (2010) Environmental Sustainability Sustainable Practice within Occupational Therapy (2012) Global Health: Informing Occupational Therapy Practice (2014) Occupational Science (2006) Occupational Therapy in End of Life Care (2016) Occupational Therapy Services in School-Based Practice for Children and Youth (2016) Occupational Therapy in Work Related Practice (2016) Statement on Occupational Therapy (2010) Telehealth (2014) Universal Design (2012) Vocational Rehabilitation (2012)
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WHO GLOBAL COORDINATION MECHANISM ON THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES
INTERIM REPORT
With preliminary recommendations from the Working Group on the integration of NCDs in other programmatic areas (WG 3.1, 2016-2017)
The WHO GCM/NCD Working Group on the inclusion of NCDs in other programmatic areas (Working Group 3.1, 2016 – 2017) was formed under Objective 3 of the GCM/NCD 2016-17 work plan to provide a forum to identify barriers and share innovative solutions and actions for the implementation of the Global Action Plan on NCDs.
Action 3.1:
Establish a Working Group in 2016 to recommend ways and means of encouraging Member States and non-State actors to promote the inclusion of the prevention and control of noncommunicable diseases within responses to HIV/AIDS and programmes for sexual and reproductive health and maternal and child health, WFOT: May include Stroke and Osteoporosis.as well as other communicable disease programmes, such as those on tuberculosis, including as part of wider efforts to strengthen and orient health systems to address the prevention and control of noncommunicable diseases through people-centred primary health care and universal health coverage.
The Working Group is co-chaired by the representatives of two Member States, one from a developed country and one from a developing country, appointed in consultation with Member States:
H.E. Beatriz Londoño Soto, Ambassador Extraordinary and Plenipotentiary; Permanent Representative to the UNOG of Colombia Dr Naoko Yamamoto, Assistant Minister for Director Global Health, Ministry of Health, Labour and Welfare, Japan
Source: Workplan for the GCM/NCD 2016 – 2017 available at: http://www.who.int/global-coordination- mechanism/working-groups/gcmwhaa6820162017apr15.pdf?ua=1
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1. Concept of Integration WFOT: In general, this first part appears to have some redundancy in the explaining the concept. It would be best if there are examples of cases or countries where the process of integration and universal health care is given to capture this concept and be more practical rather than abstract about the concept.
The persistent challenge facing countries, particularly in low and middle income countries, is to develop a sustainable health infrastructure which will provide quality health care in an integrated way. The idea of integrated health services is not new. It was the basis for the focus on primary health care in the 1980s. In 1996, integration was defined by the World Health Organization (WHO) in functional terms as “a series of operations concerned in essence with bringing together of otherwise independent administrative structures, functions and mental attitudes in such a way as to combine these into a whole”1. More recently, in 2013 UNAIDS defined programme integration as “joining together different kinds of services or operational programmes in order to maximize outcomes”2. The current challenge is to be specific about what integrated services look like in different settings and how integration can contribute to the intended aim of what WHO also defines as “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money”3.
It is important to distinguish between integrated care and integration. Integrated care is an organizing principal for service delivery, which can occur within communities, health organizations, broader health systems and across sectors. On the other hand, integration is an approach rather than an end in itself; integration describes the methods, processes and models to achieve such delivery of care. This can be achieved, for example, through organizing referrals from one service to another, through co-location, or by offering one-stop comprehensive and integrated services.
WHO’s framework on integrated people-centred health services, recently adopted at the 69th World Health Assembly, May 2016 4, provides a comprehensive definition of, and approach to, integrated health services5 that incorporates these considerations “services that are managed and delivered so that people receive a continuum of health promotion, diseases prevention, diagnosis, treatment, diseases- management, rehabilitation, and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector, and according to their needs and throughout the life-course.”
Integrating people-centred health services at the point of service delivery provide the 'right care' for the 'right people' at the 'right place'. This refers to an integrated health promotion, prevention and disease management approach that provides continuous care, in many cases focusing on specific strategies that satisfy specific needs (i.e. health promotion, diagnosis, or treatment) to a defined population. An integrated approach is not only cost-effective but also addresses inequities in health care service delivery, through promoting the provision of standardized activities to specific populations by well-
1 Integration of mass campaigns against specific diseases into general health services: report of a WHO Study Group. WHO 1965 2 Smart Investments. UNAIDS, 2013 Page 7 of 38
3 Integrated health services – What and Why? WHO Technical brief N°1, May 2008 4 Available at http://apps.who.int/gb/ebwha/pdf files/WHA69/A69 39-en.pdf 5 Definition: health services: health services include all services dealing with the promotion, maintenance and restoration of health. They include both personal and population-based health services.
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trained health workers.6
In an effective integrated service delivery model, tools, approaches and human resources are shared, with multidisciplinary teams of trained health workers providing comprehensive quality services. Integration should, however, follow a contextual, structured and sustainable approach, and is not limited to pilot projects. In addition, the necessary upstream integration of services means that services are not only integrated at the point of service, but that a systematic and unified approach is used for developing guidelines, training and supporting the roles and responsibilities of health workers, patient WFOT: and carer support, procurement, health records, continuous monitoring and evaluation and measuring quality improvement. WFOT: Establishing well thought-through outcome measures for services at every level. This ensures that lessons are shared, systems are harmonized, resources are appropriately distributed and WFOT: patient and carer satisfaction, and efficiency and quality are recognized.
Integration is not a panacea. Integration is not a cure for inadequate resources. It is not a strategy to fall back on when vertical programmes run out of funds, nor is it achieved by adding to the responsibilities of service providers without a corresponding increase in resources. Integration does not mean that specialized disciplines, programmes, personnel and services will be abolished. It does not necessarily mean that all services will be provided by multipurpose workers nor that everything has to be i ntegrated into one package. A local health service can, therefore, continue to have vertical programmes where and when the situation requires them to but, at the same time, it should be an integrated service with the capacity to sustain the activities of a vertical programnme in the long term. The two approaches are complementary. Integration is best seen as a continuum rather than as two extremes of integrated vs not integrated. Integrated care can look different at different service levels, and in differe nt contexts. In reality, there are many possible permutations. In line with the above, integration of NCD programmes into existing health programmes, such as HIV, Tuberculosis, maternal and child health, WFOT: Stroke rehabilitation, sexual and reproductive health and community-based primary health care, should be a process of horizontal/downstream integration of health services, bringing comprehensive integration of promotion, prevention, diagnosis and treatment of NCDs at the point of service delivery, including patient education, health promotion, referrals, WFOT: modification and adaptation, counseling, support on adherence and on behavior change, decentralizing clinical and lab services and community-level resource mobilization. WFOT: Has it been established why there is a need to integrate from the point of view of the end-users… that if one has communicable diseases that there is a need to prevent secondary conditions through health and wellness programmes already embedded into the programs; even for disabilities, that the risk for developing secondary disabilities may be higher when the system looks only at their current condition and neither anticipates nor prevents the development of potential conditions. For specialist care, the issue is how their activities are linked to other services. A rational referral system implies the need for specialists at secondary and tertiary levels; where resources permit, some specialization may be appropriate at the primary health care level. A recent publication demonstrates that long-established disease-specific approaches to services delivery usually do not identify commonalities between programs, thus are unable to improve joint care. 7 On the other hand, integration of programs (for example TB and NCDs) allows implementing common activities that recognize shared risk factors, comorbidities and implementing a common management approach, increasing the efficiency of interventions and optimizing resources and impact.
In additional, consideration also needs to be given to upstream NCD programme integration, as part of a wider system of coordination and inter-linkage of services at the policy and planning, human resources,
6 Narain JP. Integrating services for noncommunicable diseases prevention and control: use of primary health care approach. Indian J Community Med. 2011 Dec;36(Suppl 1):S67-71.
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7 Bates M, Marais BJ, Zumla A. Tuberculosis Comorbidity with Communicable and Noncommunicable Diseases. Cold Spring Harb Perspect Med. 2015 Feb 6;5(11). pii: a017889.
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financing WFOT: add monitoring, and surveillance levels. When implementing these complementary approaches, a mix of political, technical and administrative will and action will be required in order to effectively manage change in the way services are delivered. It may require action at several levels, including sustained leadership from the top and multisectoral and multistakeholder involvement and commitment throughout. Tooling and re-tooling of service providers is accordingly ensured to enable them to deliver the right care and the right service. It is also useful to look for good 'entry points' for enhancing integration and to consider what incentives (e.g. career enhancements) there are for health workers and their managers to change their behaviour.
Rani et al. conducted a qualitative study examining the status of governance response to NCDs at national level in different countries. They found that NCD programs were treated with a stronger managerial and implementation approach, rather than a technical expertise/advisory focus. This results in multi-sectoral plans that provide unclear prioritization, targets and costs and that diminishes their potential effectiveness. They recommend strengthening the technical and analytical capacity, at the MOH level, alongside the program management and implementation focus, developing the NCD plans in close consultation with sector-wide health and non-health stakeholders. Multi-sectoral plans should be coordinated and strengthened through optimal decision-making powers and resource commitment, complemented by sustained and integrated monitoring of outputs and evaluation of impact and effectiveness.8
Effective integration aims to result in better and more holistic patient care, prevention and treatment outcomes, ensuring enhanced health outcomes for patients. It avoids duplication of efforts, maximizes synergies, ensures comprehensive promotion and behavior change and addresses prevention and treatment of diseases with shared risk factors and common management frameworks in a simultaneous and integrated manner. Although it may provide some savings, integrating new activities into an existing system cannot be continued indefinitely without the system as a whole being better resourced. An approach that integrates the prevention and control of NCDs across progarmme areas and into service delivery strategies is, overall, cost effective and efficient but, in addition, it prioritizes NCDs in the agendas of universal health coverage and people-centerd primary health care and supports the realization of universal access and social justice.
An integrative approach that demonstrates the significant health impact of combined care is always beneficial, independent of country context, but particularly when resources are limited and countries face a double burden of disease (communicable and non-communicable diseases).9 Integration of health care delivery can lead to increased community involvement and greater overall satisfaction with those services. Integration can lead to reduced differences in access and utilization of services between gender, geographical and socioeconomic groups, and reduction of financial risks (out-of-pocket costs) for patients, resulting in greater equity in health care and outcomes.
8 Rani M1, Nusrat S, Hawken LH. A qualitative study of governance of evolving response to non-communicable diseases in low-and middle- income countries: current status, risks and options. BMC Public Health. 2012 Oct 16;12:877. doi: 10.1186/1471-2458-12-877. 9 Adeyi OSO, Robles S. 2007. Public policy and the challenge of chronic noncommunicable diseases. World Bank, Washington, DC.
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2. Overarching principles: Setting the scene
National NCD responses should be driven by a focus on people, families and communities in line with a life-course approach and population-based health care delivery strategies.
Patients, families and communities should be meaningfully engaged in every aspect of health and healthcare. WFOT: Occupational therapists actively participate in advocacy, communication and community sensitization on specific NCDs. They take advantage of existing national and international programs to provide their input on engagement in occupations for prevention and control of NCDs. Should emphasise the inclusion of those with existing disabilities. This should be explicitly mentioned because they might not be given much attention in the primary care programs when they clearly have a need to be given adequate accommodations and sensitivity among service providers at all levels.
National NCD responses should reflect best practices, emerging evidence WFOT: Maximise abilities and ensure wellbeing and quality of life. This may also mean community level programs for environmental modifications so as not to exclude those with already existing disabilities to generally receive adequate care. and the perspectives of key stakeholders. WFOT: Occupational therapists take advantage of the current paradigm shift towards NCDs in the global health delivery system. This provides an opportunity for them to conduct research and contribute towards the body of knowledge on effective community and institutional interventions to prevent and control NCDs. Regarding the phrase perspectives of key stakeholders. ‘’who determines that they are key? What qualifies them or what is the composition of such?
Health care systems need to prioritize disease prevention and health promotion WFOT: There is growing evidence that occupational therapists do not confine themselves in clinical settings but also take up community roles as public health professionals to prevent and control NCDs. Relative to occupational therapy, the most cost effective insurance mechanism to NCDs is preventing them from coming to the hospital for treatment through community interventions based on empirical evidence. NCDs should be widely incorporated in strategies for people-centered integrated health services and UHC , with the understanding that existing service delivery programs can be enhanced/improved/made more efficient by incorporating NCDs: underscoring the co-benefits of integrative approaches, particularly be addressing shared risk factors and co-morbidities. WFOT: Countries should develop national NCDs strategies where occupational therapists actively participate providing their input toward prevention and control of NCDs “An effective national response for the prevention and control of NCDs requires
multistakeholder engagement, to include individuals, families and communities, intergovernmental organizations, religious institutions, civil society, academia, the media, policy-makers, WFOT: Rehabilitation professionals, local government, voluntary associations and, where appropriate, traditional medicine practitioners, the private sector and industry. The active participation of civil society in efforts to address NCDs, particularly the participation of grass - roots organizations representing people living with NCDs and their carers, can empower society and improve accountability of public health policies, legislation and services, making them acceptable, responsive to needs and supportive in assisting individuals to reach the
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highest attainable standard of health and well-being. Member States can also promote change to improve social and physical environments and enable progress against NCDs including through constructive engagement with relevant private sector actors.” 10
WFOT: Suggest clarifying or adding professional volunteers (e.g., WFOT and other disciplines’ leadership; other occupational therapy and other disciplines’ national association leadership)
Strong and sustained high-level political commitment to drive cross-sectoral integrated NCD- specific and sector-wide approaches.
Ministry of health and sub-national health authorities need to build on process of revision and/or development of national cross-sector health policies and strategies that incorporate the prevention and control of NCDs and that ensure adequate prioritization, costing and appropriate targets. Ensuring full realization of the relevant commitments adopted in the 2011 and 2014 UN General Assembly High-Level Political Declarations. The sector-wide health plans should reflect NCDs in proportion to their public health importance and in line with in indivisible and integrated SDG-approach.
10 WHO Global NCD Action Plan 2013-2020, Paragraph 28
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Policy-makers can provide leadership by making smarter investments for health, engaging relevant sectors for enhanced national multisectoral collaboration and coordination, enabling proper participation of communities, and ensuring institutional and financial mechanisms are fit for purpose. Also, by building institutional and individual capacity of health leaders WFOT: While occupational therapists conduct research, it important that their capacity is supported/developed (at the national, sub-national and facility level) to transform service delivery with a focus on developing quality interpersonal and inter-institutional relations. As integrated people-centred health care services reverse the focus from institutions and diseases to people, resource planning should evolve accordingly from vertical programs and rigid norms to “smart” capacity planning based on well-defined population needs and health pathways (flows) across levels of care, consistent with the model of care and (redefined) roles and missions of health care organizations.11 Promoting whole-of-government and whole-of-society responses: Effective NCD prevention and control require multisectoral approaches at the government level including, as appropriate, a whole-of-government, whole-of-society and health-in-all policies approach across such sectors as health, agriculture, communication, customs/revenue, education, employment/ labour, energy, environment, finance, food, foreign affairs, housing, industry, justice/security, legislature, social welfare, social and economic development, sports, trade, transport, urban planning and youth affairs (Appendix 5). Approaches to be considered to implement multisectoral action could include, inter alia:
i. self-assessment of Ministry of Health, WFOT: Include departments of water supply and waste management. These are essential components of a whole of society approach that greatly affects health.
i. ii. assessment of other sectors required for multisectoral action, iii. analyses of areas which require multisectoral action, iv. development of engagement plans, v. use of a framework to foster common understanding between sectors, vi. strengthening of governance structures, political will and accountability mechanisms, vii. enhancement of community participation, viii. adoption of other good practices to foster intersectoral action and
ix. WFOT: Training, monitoring and evaluation.12
Implement responses for the prevention and control of NCDs based on human rights and equity-based approaches, and poverty-reduction strategies.
Include strategies for the prevention and control of NCDs in national social/development plans Particular focus on vulnerable populations and patients with multiple chronic diseases (co- morbidities). WFOT: specify- we are referring to the elderly, children, women and persons with disabilities. These principles and approaches are relevant for all countries, whether with high, medium and low revenues, with mature or fragile health system
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11 WHO’s Draft Call for action for Integrated People Centred Health Services (IPCHS) 12 WHO Global NCD Action Plan 2013-2020, Paragraph 27
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WHO is in the process of finalizing the Innov8 Approach for Reviewing National Health Programmes to strengthen action on equity, gender, human rights and social determinants of health. The Innov8 Approach aims at ensuring that “no one is left behind” in health programmes . WFOT: Could include: 1. Inclusive national level health system management policy by considering different levels of health services 2. Development of a proper guideline on a referral mechanism
Involvement/engagement/empowerment of civil society is essential in formulating and implementing policy decisions.
Integration is grounded in an institutional culture of collaboration and engagement with the community, as a precursor to engagement with service users. It builds on encounters between the community, patients and their families with health service providers. This represents a major shift of focus, from institutions to people, recognizing the complexity and the unique value of their experiences and needs. Youth, family, communities and patients are informed about their rights or entitlements and can raise awareness and advocate for integrative approaches. Empowering and engaging people with information, skills and resources that they need is essential in order to make effective decisions about their own health, and be articulate and empowered users of quality health services.
3. Draft Preliminary Recommendations
3.1 Governance/Upstream/Vertical
Recommendation 1 All programme and health system funding, management WFOT: Monitoring and Evaluation and service delivery should support
integrated people-centered health care and population-based health strategies.
Policy options: Integrated vertical and cross-cutting programmes and strategies should promote and prioritize a focus on people, families, and communities through a life-course approach, oriented towards the implementation of integrated people-centred primary health care and universal health coverage. Promotion and preventive approaches should be the foundation of a multisectoral NCD response, with clear investments in holistic care prioritizing health promotion and primary prevention strategies that support people’s health and wellbeing. WFOT: Occupational therapists
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This will require effective promotion, adaptation and implementation of WHO’s Framework on integrated people-centred health services. 13 It calls for a comprehensive approach with a greater emphasis on prevention and effective management of diseases, coordination of care, and multidisciplinary teams. Engaging communities, patients, and families is an essential component of this approach. Governments should channel vertical and cross-cutting resources into creating more equitable, accessible and sustainable health services that seek to better co-ordinate care around people’s needs and to secure improved health for people and populations. This may require moving away from line budgeting and/or fee-for service payment to mixed payment systems (e.g. partial capitation with some fee for service for priority services of high effectiveness and public health importance) This supposes strong leadership and management capacity of local health authorities as it implies decentralization of decisions on resources allocation.
Recommendation 2
Policy makers require context-specific evidence, best practices and business cases for effective integration in order to ensure prioritization and integration of NCDs and other program areas in national health strategies.
Policy options: Ensure integration of NCDs and other program areas, in particular with HIV, TB, MCH, SRH, supported by evidenced-based, focused and shared joint-indicators. WFOT: These are perfect examples where occupational therapists can provide their input particularly in MCH. These examples are good for making the readers understand what an NCD is, they might restrict the future NCD work on these areas. Build context/country-specific business cases for integration: burden of disease, health and economic impact, action vs inaction. This is critical, for health teams and hospitals, among other stakeholders, to understand the health needs of the population they serve and adapt supply of services, to implement population-based services, and to better manage patient’s individual needs. Build on and enhance body of evidence demonstrating effectiveness and impact of integrative approaches that have been experimented and implemented in various settings, with a particular focus on implementation research. Before implementing best practices, consider recognizing local specificities and regulating local adaptation to needs through priority public health interventions Develop, implement and disseminate concrete models for NCD management – considering promotion, prevention and treatment access - including NCD specific indicators Consider existing tools (i.e. WHO’s Innov814, and PEN15)
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13 WHO Framework on integrated people-centred health services. Geneva: World Health Organization; 2016. http://www.who.int/servicedeliverysafety/areas/people-centred-care/en/
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Recommendation 3 Governments require focused support from international development partners and intergovernmental organizations for effectively implementing the integration of the prevention and control of NCDs with other programme areas, in line with national priorities.
Policy options: International development partners, intergovernmental organizations and national, regional and international development plans (i.e. donors, development aid agencies, UNIATF, UNDAF, CCS, Development plans) should support for and provide follow-up of integrative NCD strategies aligned with country priorities Technical assistance and guidelines from UN Agencies, including WHO, should promote and implement coordination, alignment and integration. National leadership should promote and ensure alignment of international development support with national priorities on integrative strategies. Civil society (i.e. policy-makers, health professionals, communities and patients) can ensure support from the international community. WFOT: Inter country collaborations should be incorporated.
Recommendation 4 Enhanced government commitment is required for building adequate and sustainable health workforce to manage and integrate NCDs.
Policy options: Promote the production, training and retention of health workers with a view to facilitating adequate deployment of a skilled health workforce within countries and regions, in accordance with the World Health Organization Global Code of Practice on the International Recruitment of Health Personnel.16 WFOT: Suggest tool kits to enhance the cost-effectiveness of training of health workers Integrate the prevention and control of NCDs in all phases of health workforce training, development and management, as well as in wider health sector strategies.
Map local and national health workforce resources and requirements, including a
comprehensive review of health professional training institutions, based on the health needs of
14 Global Innov8 Training And Orientation - An approach to reviewing national health programmes to better address equity, gender, human rights and social determinants of health. Manila: World Health Organization; April 2016. http://www.who.int/social determinants/Global-Innov8-Training-and-Orientation-meeting.pdf 15 Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low- Resource Settings. Geneva: World Health Organization; 2010. http://www.who.int/nmh/publications/essential ncd interventions lr settings.pdf
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16 World Health Organization, Sixty-third World Health Assembly, Geneva, 17–21 May 2010, Resolutions and Decisions, Annexes (WHA63/2010/REC/1), annex 5
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the communities and support/adjust pre- service and in-service training curricula and approaches, as appropriate to local context. Pre-service training Review and update health workforce curricula and methods Continuous training, updated protocols Competencies, skill sets, knowledge skills Performance measure, feedback and incentive for integration Strengthen the ability of national institutions to develop and implement more effective evidence- based health workforce policies and strategies, including appropriate regulation for the health workforce, adopting a person-centred health care delivery model and a diverse, sustainable skills mix geared to primary health care and supported by effective referral and links through all levels of care to the social services workforce.
Recommendation 5 Governments need to ensure the promotion, development and implementation of High-level Multisectoral Mechanism/Commission on NCDs with clear leadership from the health sector.
Policy options: Consider establishing, as appropriate to the respective national context, a national multisectoral mechanism, such as a high-level commission, agency or task force for engagement, policy coherence and mutual accountability of different spheres of policymaking that have a bearing on non-communicable diseases, in order to implement health-in-all-policies and whole-of- government and whole-of-society approaches, and to monitor and act on the determinants of non-communicable diseases, including social and environmental determinants. 17 Multisectoral coordination mechanisms need to be strengthened with optimal decision-making powers, resource commitment and monitoring of outputs, with a particular focus on strengthening governance and accountability. Multisectoral coordination mechanisms should demonstrate effective leadership in closing the gaps between policy-makers, academics and researchers, managers, providers and users, in order to identify and evaluate opportunities/bottlenecks, scale up and/or sustain and needed systemic changes (including in the regulatory frameworks) to generate and translate evidence for policy.
Multisectoral coordination mechanisms require an appropriate and comprehensive stakeholder mapping, with a view to creating effective networks between health and other sectors and
17 United Nations General Assembly. 2014. Outcome Document of the High-Level Meeting of the General Assembly on the Comprehensive Review and Assessment of the Progress Achieved in the Prevention and Control of Non-communicable Diseases. Resolution 68/300, 10 July 2014. 30(a)(vi). Available at www.who.int/nmh/events/2014/a-res-68-300.pdf
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establish a shared diagnosis of the situation and identify most relevant and feasible interventions, through a participatory and inclusive processes. They require the development of an implementation plan with clear goals, measurable objectives and defined roles and responsibilities, WFOT: referral systems, including for different stakeholders on how they work
3.2 Service delivery/Downstream/Horizontal
Recommendation 6 Governments need to ensure that quality NCD services are incorporated and integrated in primary health care and that quality and timely referral systems are functional. Policy options: Promote, adapt and implement WHO’s Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings.18 The definition or revision of the benefit package (“what services should be made available and under what conditions”) is a foundational issue as it fosters a rights-based approach, enabling monitoring and accountability for effective availability of services and it drives organization and financing of services. Ensure that competent workforce with appropriate technical skill in specialty care is available to back up referral systems and screening programs. WFOT: Need to ensure a strong monitoring mechanism
Recommendation 7 Integration of the prevention and control of NCD at service delivery level should be comprehensive/horizontal, but may require starting from the successes of integrating with vertical programs (such as HIV, TB, MCH, SRH).
Policy options: Promote the clear value of providing a log frame as a tool for mapping entry points for integration across program areas and with a focus on primary health care and universal health coverage, with a view to compile and disseminate an “integration roadmap”. Promote, adapt and implement lessons learned and scale up best practices from countries which have successfully added NCD components to existing programme areas WFOT: How will best practices be shared?
Recommendation 8 Effective integration of NCDs with other programme areas requires the optimal and efficient use of
18 Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings. Geneva: World Health Organization; 2010. http://www.who.int/nmh/publications/essential ncd interventions lr settings.pdf Page 23 of 38
existing or available human resources, in particular through “task-shifting or task sharing”, complemented by adequate resources, supervision and oversight and incentives.
Policy options: This will require “the best use of limited resources and ensuring that they are deployed strategically, recognizing the potential of multidisciplinary team-based approach at the primary care level for integrated people-centered health care, exploiting the potential contribution of different typologies of health workers, operating in closer collaboration and according to more rationale scope of practice.”19, in order to effectively match the supply and skills of health workers to disease burden and population needs. A progressive shift in the demand for patient-centred care, community-based health services, and personalized long-term care demand for a substantial growth of health workforce with integrated skills. WFOT: Promote and implement task-shifting/sharing which also covers volunteers, when appropriate. WFOT: note the importance of training of volunteers WFOT: Collaboration with local existing non-government health programmes to use their networks and workforce to promote and control NCD’s. Realizing this agenda requires the following: appropriate regulation for health workforce education on NCDs; a more sustainable and responsive skills mix for an integrated response, harnessing opportunities from the education and deployment of community-based and midlevel health workers; improved deployment strategies and working conditions; incentive systems; enhanced social accountability; inter-professional collaboration; and continuous professional development opportunities; and career pathways tailored to gender-specific needs in order to enhance both capacity and motivation for improved performance 20 Community health workers (CHWs) should be clearly recognized by integrating them into national health workforce plans for NCDs, adequately supported, WFOT: trained, resourced and incentivized.
Recommendation 9 Governments should invest in research and implementation of innovative technologies, including e- Health and m-Health, to support integration, scale-up and outreach of NCD strategies and programs
Policy options: Recent advances in information technologies (shared electronic records, WFOT: Home based service, m-health, telemedicine, less invasive procedures) provide support for successful implementation. WFOT: Important to secure private foundation funding for m-health strategies. Promote, adapt and implement lessons learned and scale up best practices from countries which have successfully prioritized these investments.
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19Draft Call for action for Integrated People Centred Health Services (IPCHS) 20 World Health Organization. Global strategy on human resources for health: Workforce 2030. Sixty-ninth World Health Assembly. 2016
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WFOT: Section 4 is currently labelled ‘Tables’; suggest that this be renamed to reflect the actual content or broken into sections per the three tables. There is a deal of repetition within this section and with other parts of the paper that could be better synthesized. In particular, it would be valuable to have some applied applications or case examples to illustrate potential best practice or proposed strategies, and/or provide more explicit introductory statements.
Section/Table 4.1 also refers to ‘principles’ (i.e. there are Overarching Principles and Key Principles in the document)… and while these 10 principles for generic successful health system integration have relevance providing more applied implementation examples would be valuable in supporting action on the integration of NCDs with other health programs as listed in the Action statement. Indeed, throughout the document, there is little explicit/articulated links back to the listed programs/responses with which NCDs are to be included.
4. Tables
4.1 Ten key principles for successful health systems integration
The table below, based on Ten Key Principles for Successful Health Systems Integration, by Suter et al.21, identifies ten universal principles of successfully integrated healthcare systems which may be used by decision-makers to assist with integration efforts. Recognizing there is no one-size-fits-all model or process for successful integration these principles define key areas for restructuring and allow organizational flexibility and adaptation to local context. 2. Patient, family and community focused Principle Implementation example 1. Comprehensive services across Integrated health systems are responsible for health promotion the continuum of care and management from primary through to tertiary care, in close cooperation with community-based organizations and health systems. These cover preventive, curative and rehabilitative delivery of services. WFOT: Occupational therapists work closely with other professionals to ensure effective continuity of care. They inform other members in terms of what they can offer so that clients do not miss the benefits for them of occupational therapy.
Service planning and information management are driven by needs assessments WFOT: Occupational therapists are integral in these assessments as occupational science experts and processes designed to improve patient and family satisfaction and outcomes both for individual patients and for populations. Integration encompasses the rights of patients. Integrated health systems should be easy for patients to navigate and should prioritize patient and community engagement, participation and empowerment.
WFOT: Need to include the family issues.
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3. Geographic coverage and equity The system takes responsibility for ensuring affordable WFOT: and equal access to and appropriate utilization of needed quality services for clearly defined populations and geographic areas
Best practice guidelines, health promotion and clinical care pathways and decision-making tools standardize and enhance health promotion and quality of care.
5. Performance monitoring Monitoring systems that consist of protocols and procedures, measure care processes and outcomes at different levels, and are linked to reward systems to promote the delivery of cost-effective quality care.
6. Information systems Computerized information systems allow effective tracking of
21 Based on Suter E, Oelke ND, Adair CE et al. Ten key principles for successful health systems integration. Healthc Q 2009; 13 Spec No:16–23.
4. Deliver care based on evidence- informed guidelines
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utilization and outcome data across the continuum of care and serve consumers, payers and providers; facilitates effective communication, enables system wide patient registration, scheduling coordination, and management of clinical data. WFOT: Documentation issues should be incorporated
7. Organizational culture and Committed leadership brings individuals and inter-professional leadership and multidisciplinary teams together, promotes the vision and mission of integration, ensures opportunities, resources, incentives and rewards for staff learning, performance and ownership of the process WFOT: without showing any bias. 8. Health professional integration and care delivery Physicians, nurses and nurse practitioners, WFOT: Rehabilitation through inter-professional professionals including those from the private sector, are and multidisciplinary teams effectively integrated at all levels of the system and play leadership roles in health system design, implementation and operation; well-functioning inter-professional and multidisciplinary teams result in efficient care and enhanced satisfaction and health outcomes. Integration is embedded in training curriculum of different cadres of health care professionals.
9. Governance structure Governance structures promote integration and are diversified, ensuring representation from a variety of stakeholders involved in the delivery of healthcare, including the health work force and the community. The organizational structure is independent of, but accountable to, government and the health organizations. Strategic alliances with external stakeholders, government and the public are essential, as are incentives that influence providers’ attentiveness to costs and quality of services. The complexity of systems requires effective and inclusive coordination for accountability and decision-making, with convergence at policy, planning and budgeting levels so that ‘integration’ is embedded in the entire health delivery system.
10. Financial management Financing mechanisms allow pooling of funds across needed services, for example, through global capitation, which pays for all insured health and some social services required by the enrolled population. Finance mechanisms to support health system strengthening are equally relevant for integration. (Outsourcing the services of transport/courier companies to accommodate the distribution/delivery of all program commodities rather than having different mechanisms per program)
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4.2 Potential efficiency gains from integration
The below table on potential efficiency gains from integration is extracted from Sweeney et al.22 to describe the potential effect of integration at each level of a health system. It recognizes that integration can contribute to efficiency gains beyond the improvement in allocative efficiency at the service level.
1. Integration of governance (such as through coordination of strategic and operation planning and performance monitoring) may improve technical efficiency by sharing scarce resources (including human resources, such as clinicians, skilled planners and managers.) Joint or coordinated planning and management of scarce resources, monitoring and evaluation, and reporting may also improve allocative efficiency.
2. For patients, communities and families integration may lead to better quality care, improved health behaviors and action for early diagnosis, less fragmented services, better access, improved health promotion, higher levels of continuity of care, better re ferral systems, and greater satisfaction with care and improved outcomes. WFOT: This is a very idealistic statement that needs to be grounded with realities in the field. Integration also may reduce patient/community-level costs resulting from improved self-management, fewer visits to facilities, greater proximity of services and reduced delays in seeking consultation to access diagnosis and treatment. WFOT: and rehabilitation services
3. Integration of financing may improve technical efficiency by merging and reducing the costs of separate financing and reporting systems. Co-ordinated financing may also impact allocative efficiency by reducing perverse incentives that may be created by competing programmes.
4. Health management systems integration can facilitate improvements in technical efficiency through reductions in management systems costs, such as through joint procurement, sharing of middle managers, joint training and supervision, sharing information, WFOT: joint monitoring education and communication materials, and joint management information systems.
5. Facility integration can contribute to improved outcome and reductions in facility costs resulting from joint utilization of space, major equipment, WFOT: management costs and other fixed factors of production.
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22 Based on Sweeney S, Obure CD, Maier CB, Greener R, Dehne K, Vassall A. Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience. Sex Transm Infect. 2012; 88:86.
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4.3 Potential challenges for integration of NCDs and possible actions to overcome them
WFOT: Table 4.3 is a strength of the document. Generally the challenges identified resonate with experience and the table contains some practical guidance; some refinement of articulation of dot points and terminology will further assist comprehension. Illustrative examples from different contexts might enhance adoption.
Tables, 4.3 #3. , an appreciation of diversity of views and the availability of trained facilitators to ensure all voices are heard will be of extreme importance to ensure social and occupational justice in decision-making #5, Use of something like MOOCS or tool kits to enhance the cost-effectiveness of training of health workers may help ease the overburden – which is a very real concern #6, include health communication experts in solutions related to health literacy
Challenge Context Actions 1. Lack of political will Lack of strong leadership (Ministries National and/or subnational for prioritizing and of Health and/or subnational level) centralized multi-sectoral coordination implementing Lack of sustainability; rapid turnover mechanism/agency integration of leaders; service delivery systems Develop context-specific business case without engagement of sustainable documenting the evidence of costs and clinical leaders and institutions benefits, and rationale for integrating Varying priorities of leaders WFOT: 1. NCDs into identified services educational qualification of different sub national Sustainable M&E and accountability level leaders. 2. political bias frameworks;
Country ownership of health and development assistance A clear understanding that the attainment of the SDGs requires integration; thus, national strategic plans, anchored on reaching the SDGs, should consider integrated approaches. WFOT: develop a specific selection criteria also strong monitoring system.
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Need to define and map priorities based on local context, such as country and community needs, geographical situation, available resources, and existing organization and management infrastructures. WFOT: inform the community on NCD Develop indicators to assist in monitoring the whole system and its constituent parts at local level, to measure quality of service, equity of access and output against the cost Log frame Decentralization of health service delivery Clarity on definition of integration and how integration could be achieved by all stakeholders involved Clearly defined objectives, targets, plans and outcome monitors for the approach 3. Lack of health Diversity of views about the National and/or subnational system and issues/priorities across different multisectoral coordination stakeholder sectors, e.g. different concerns mechanism/agency commitment, from public health professionals, Coordinated planning and well- coordination and politicians, economists and civil resourced communication strategy to consensus society, leading to fragmented achieve a paradigm shift that promotes
2. Difficulty in Lack of guidance and best defining local practices for informing evidence-based integrated services approaches for Lack of context-specific effective evidence and data integration and Evidence stays in piloting developing stage, without guidance or national evidence on scale proposals on up/mainstreaming integration Lack of approaches that fit local context and infrastructure WFOT: Different types of local norms and value as well as practices.
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approaches to their solutions a holistic view of the health by different Lack of cross-sectoral WFOT: and inter sectors professional WFOT: an appreciation of diversity of views and communication within governments the availability of trained facilitators to ensure all Poor understanding of, and voices are heard will be of extreme importance to ensure social and occupational justice in decision- agreement on, terminology and making activities regarding integration Advocacy for integration initiated across programme areas with and among relevant ministries Sectors’ desire to defend “territorial at both national and district levels, gains and rights”, unaware of Community mobilization interlinkages between their work Log frame and other sectors A district WFOT: and administrative area Difficulty in identifying opportunities development committee to be set up and co-benefits for integration at with the task of preparing an overall different stakeholder levels and district development plan. This plan will ways in which activities can include clear roles to be taken by the reinforce one another. various levels and elements in Competitive mindset between implementing the plan, with a clear health system levels, definition of accountability and programmes and institutions responsibility of all parties. WFOT: Need Barriers to inter-professional to get a common level of understanding collaboration among all stakeholder about their roles in a Perception that less funded particular disease. programs have less priority. Advocacy for attitude change to 4. bring about cooperation instead of Health systems competition regardless of budgets prioritization of or funds available. WFOT: A proper single-disease implementing and monitoring chain should treatment be developed (who monitors who and how) WFOT: Agree. Primary Partnership-building to allow different health care levels to share vision and goals, and to approaches, need be prepared to work together to achieve to be more these goals using common resources attractive to health and technologies professionals Programmes and systems not under a coordinated command at national, district, municipal or community level. Perpetuation of separate planning, reporting, monitoring, evaluation and accountability mechanisms focused on specific programme areas, in many cases to meet donor demands and in context of projects rather than institutionalizing the processes and the systems. Siloed programme management including funding: Resources/funds are generated according to specific program activities; and similarly, funds are
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made available in response to National and/or subnational specific program activities. multisectoral coordination Acute care mindset vs promotion mechanism/agency and prevention NCDs well integrated into national Sustained funding gaps for many health and development plans program areas, e.g. NCDs and Reframing national development plans SRH are underfunded and may be to incorporate SDGs, including UHC and competing for funds a rights-based approach to population health Focus is on what works well for the A district development committee to be set up with the task of preparing an overall district development plan. This plan will include clear roles to be taken by the various levels and elements in implementing the plan, with a clear definition of accountability and responsibility of all parties. Advocacy for attitude change to bring about cooperation instead of competition. Engage with health sector in developing the integration plans, and communicate a clear vision that has benefits for the service, for patients (win-win scenarios) Develop promotion and prevention strategies that overarch
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services, rather than being common/related diseases and not only person/client-centred and with a disease-specific focus (e.g. focusing on what works best for campaigns on proper nutrition, nutrition people/patients. advisories) Integrating existing structures or systems and changes in roles can give rise to competition rather than integration 5. Overloaded health workforce and In the context of a shortage of Task shifting: moving tasks away from unclear health workforce, requirements for more specialized health professionals to development and multidimensional skills and less specialized health workers support for expertise may overburden clinicians Comprehensive mapping of local integration and community health workers, health workforce WFOT: More private Multiple responsibilities may be sector engagement to get a quality full health added to community staff without workforce. being cognizant of their current Comprehensive professional training: workload and without adequate an updated curriculum with analysis training including in prioritization of functions and task definitions in an or problem solving, leading to integrated health system. diluted messages and services, Training and continuous development poor quality of interventions, poor of health professions should reflect a patient satisfaction and potential holistic approach to health care. staff burnout and poor retention. Training should allow staff to have the Families may also be at risk of skills and knowledge to appreciate the receiving too much information at role of and work with and support one time, not knowing how to colleagues across disciplines. prioritize or digest all of the Clear job descriptions, revised information received. periodically, that define staff roles and Inadequate advocacy and responsibilities for integrated sensitization on the benefits programming. of integration Simple guidelines, standardized Limited availability of health protocols; consistent training of both workforce data front-line and specialized health care Difficulties in deploying health workers workers to rural, remote and Incentivizing organic and community underserved areas health workers WFOT: Lack of private sector Employ reward or merit system for engagement to produce qualified health successful integrated practices and workforce. initiatives Strong supervision, coaching, accountability and incentive mechanisms WFOT: Use of something like Massive Open Online Course (MOOCS) or tool kits to enhance the cost-effectiveness of training of health workers may help ease the overburden – which is a very real concern
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6. Poor community Lack of experience in or support of Prioritization of health education and engagement and community-based action or task health literacy programs and strategies, empowerment shifting/sharing by many health defined for specific audience groups. professionals. Country owned solutions with Lack of understanding of knowledge demonstrated effects which are and resources found in community then ready to take to scale. health workers and support Incorporation of integrative principles in systems. professional training/curriculum Centralized health services and, in Decentralization of health services, with some cases, little tradition of active enhanced collaboration at local levels WFOT: include health communication experts in solutions related to health literacy
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partnership between government sector and communities. Multi- Civil society empowerment and sector or community participation may be hampered by participation, particularly through bureaucratic structures, and community action for health multistakeholder engagement becomes a bottleneck for integration. WFOT: Lack of government and coordination mechanisms positions in the primary health system for health providers especially and/or incentives WFOT: concerned with health and wellness. No therapy personnel. No personnel Community awareness creation by dedicated for the elderly or persons with special needs. respecting their beliefs. Create an environment where
communities are empowered to engage Limited health literacy in some on specific tasks that they can sustain communities WFOT: Community local across time (e.g. assigning community malpractices, norms and value health workers as treatment partners for diabetic patients undergoing TB treatment)
7. Health system Lack of implementation research Enhance priority of organizational research related to integration of services studies in support of integration, through and the process of organizational engagement of academia and local and change and decision-making international technical support processes to support integration Strengthen political commitment, Shortage of appropriate research financial support, multidisciplinary methods and skills. input and a long-term commitment to Over-reliance on traditional implementation studies, public health institutions. Develop policy frameworks for Lack of evidence on how to scale-up integrating top-down and bottom-up or roll out pilot projects throughout approaches to organizational change, the whole service/system. WFOT: Adequate funding for research and development
8. Weak and siloed Limited indicators to measure Integration of governance, through joint monitoring and integration coordinated planning and management, evaluation Current M&E tools address specific monitoring and evaluation and reporting programs, not integration outcomes Adapt/create a set of minimal key joint or impact WFOT: Establish MRM indicators to monitor and evaluate (Monitoring and Result Measurement) progress system rather than Monitoring and Develop a global or regional Evaluation. compendium of indicators related to integration that countries can adopt for their own monitoring
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