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A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions

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A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions 47980 WORLD BANK WORKING PAPER NO. 166 Clearing the Global Health Fog Public Disclosure Authorized A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions Rifat Atun Thyra de Jongh Federica V. Secci Kelechi Ohiri Public Disclosure Authorized Olusoji Adeyi V H P R I O R I T I E S T O O L S S Y S T E M S N R E C A I N T E R V E N T I O N R I L E I U V E T G L C T I N H H O R I Z O N T A L R C Public Disclosure Authorized C I A C L I E E V I D E N C E T D A T A S T U D I E S E I L P I P O P U L A T I O N P D O G M A F L N R N R A O G L O B A L T D I A G O N A L A S Y C O V E R A G E H Public Disclosure Authorized THE WORLD BANK WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page i WORLD BANK WORKING PAPER NO. 166 Clearing the Global Health Fog A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions Rifat Atun Thyra de Jongh Federica V. Secci Kelechi Ohiri Olusoji Adeyi THE WORLD BANK Washington, D.C. WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page ii Copyright © 2009 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First Printing: March 2009 printed on recycled paper 1 2 3 4 5 12 11 10 09 World Bank Working Papers are published to communicate the results of the Bank’s work to the development community with the least possible delay. The manuscript of this paper therefore has not been prepared in accordance with the procedures appropriate to formally-edited texts. Some sources cited in this paper may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the International Bank for Reconstruction and Development/The World Bank and its affiliated organizations, or those of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank of the legal status of any territory or the endorsement or acceptance of such boundaries. The material in this publication is copyrighted. Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law. The International Bank for Reconstruction and Development/The World Bank encourages dissemination of its work and will normally grant permission promptly to reproduce portions of the work. For permission to photocopy or reprint any part of this work, please send a request with complete information to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA, Tel: 978-750-8400, Fax: 978-750-4470, www.copyright.com. All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA, Fax: 202-522-2422, email: [email protected]. ISBN-13: 978-0-8213-7818-2 eISBN: 978-0-8213-7936-3 ISSN: 1726-5878 DOI: 10.1596/978-0-8213-7818-2 Library of Congress Cataloging-in-Publication Data has been requested. WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page iii Contents Acknowledgments. v Acronyms and Abbreviations . vii Summary. ix 1. Introduction . 1 2. Methodology . 3 The Conceptual Framework for Analysing Integration of Targeted Health Interventions into Health Systems . 3 3. Results . 7 Outcomes Reported in the Studies Analyzed . 7 The Extent and Nature of Integration of Health Interventions into Critical Health Systems Functions . 12 The Extent of Intervention Success in the Studies Analyzed . 18 How the Context Influences the Extent and Nature of Integration . 19 4. Discussion . 23 5. Conclusions . 25 Appendixes. 27 A. Search Strategy and Methods . 29 B. Summary of the Included Studies. 31 C. Contextual Factors . 57 References . 63 LIST OF TABLES 1. Critical Health Systems Functions and Elements of Integration . 5 LIST OF FIGURES 1. Flow Chart Representing the Selection Process for Studies Included in the Review. 4 2. The Extent and Nature of Integration by Targeted Health Intervention and Intervention Success as Reported in the Study. 13 iii WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page iv WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page v Acknowledgments he work program underpinning this paper was initiated and funded by the World Bank Tand entitled “Integration of Health Systems and Priority Health, Nutrition and Popu- lation Interventions.” Preparation of the paper was co-funded in a collaborative exercise by the Center for Health Management at Imperial College London and the World Bank. In that context the authors acknowledge consultations with a number of colleagues during an international consultation hosted by the World Bank in May 2008, and comments from several reviewers who helped to improve the manuscript. The reviewers were Tom Novotny (Professor, University of California, San Francisco) and Richard Coker (Reader, London School of Hygiene & Tropical Medicine). Sylvia Robles reviewed the initial version of a Cochrane Review, which was an earlier step in this exercise. Logan Brenzel and Peter Berman commented on the conceptual framework on which the paper is based. Sonalini Khetrapal provided comments on an earlier version of the paper and Inas Ellaham helped with formatting. The authors alone are responsible for the contents of the paper. About the authors: Rifat Atun, MBBS, MBA, FRCGP, FFPH. Professor of International Health Manage- ment, Imperial College, London. E-mail: [email protected] Thyra de Jongh, MSc, DIC, PhD. Researcher, Centre for Health Management, Impe- rial College London. E-mail: [email protected] Federica V. Secci, MSc. Doctoral Researcher, Centre for Health Management, Imperial College London. E-mail: [email protected] Kelechi Ohiri, MD, MPH, MS. Health Specialist in the Human Development Network of the World Bank. E-mail: [email protected] Olusoji Adeyi, MD, DrPH, MBA. Coordinator of Public Health Programs in the Human Development Network of the World Bank. E-mail: [email protected] Cover design: concept by Olusoji Adeyi, text by Olusoji Adeyi and Sonalini Khetrapal, graphics by Stuart K. Tucker. v WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page vi WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page vii Acronyms and Abbreviations AIDS Acquired Immune Deficiency Syndrome BINP Bangladesh Integrated Nutrition Project CWG Community Working Groups EPI Expanded Program for Immunization EPOC Cochrane Effective Practice and Organisation of Care Group FP Family Planning HIV Human Immunodeficiency Virus ICDDR,B International Center for Diarrheal Disease Research, Bangladesh IDCS India Integrated Child Development Services IMCI Integrated Management of Childhood Illness LHWP Lady Health Worker Program M&E Monitoring and Evaluation MCH Maternal and Child Health PHC Primary Health Care PPI Pulse Polio Immunization TB Tuberculosis UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCT Voluntary Counselling and Testing WHO World Health Organization vii WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page viii WP166_FM.qxd:WP166_FM 3/13/09 5:36 PM Page ix Summary longstanding debate on health systems organization relates to benefits of integrating Ahealth programs that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration argu- ing the relative merits of each approach. Recently, the debate has been rekindled due to sub- stantial increases in externally funded programs for priority health, nutrition and population interventions and enhanced international efforts aimed at health systems strengthening. However, all too frequently these arguments have not been based on hard evidence. In this paper we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of integration of targeted health programs that emphasize specific interventions into critical health systems functions (defined in the Methodology Section), (ii) how the integration or non-integration of health programs into critical health systems functions in different contexts have influenced program success, (iii) how contextual factors have affected the extent to which these programs were integrated into critical health systems functions. We use a new conceptual framework to guide the analysis. The review evaluates peer-reviewed studies that focus on health interventions, and which have been introduced on a regional or national scale. The debate on health interventions has tended to narrowly focus on vertical or inte- grated descriptors. However, our analysis shows this to be a false dichotomy as few inter- ventions are purely vertical (single-disease oriented) or horizontal (fully integrated into mainstream functions) health system. As this review shows, in practice the nature of the problem, the interventions to address these and the adoption and assimilation of health interventions in health systems vary greatly in different contexts, as does success. The purpose, nature, speed and the extent of integration also vary—in part, dependent on the intervention complexity, the health sys- tem characteristics and the contextual factors.
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