Integrated health service delivery networks: concepts, policy options and road map for implementation in the Americas

Abstract

Health systems in the Americas are characterized by highly fragmented health services. Experience to date demonstrates that excessive fragmentation leads to difficulties in access to services, delivery of services of poor technical quality, irrational and inefficient use of available resources, unnecessary increases in production costs, and low user satisfaction with services received. Health services fragmentation manifests itself in multiple ways at the different levels of the health system. Regarding the overall performance of the system, fragmentation is evident in the lack of coordination across the different levels and sites of care, duplication of services and infrastructure, unutilized productive capacity, and the provision of health services at the least appropriate location, particularly hospitals. Regarding the experience of system users, fragmentation is apparent in the lack of access to services, loss of continuity of care, and failure of services to meet users’ needs. Although fragmentation is a common challenge in the majority of the region’s countries, its magnitude and primary causes differ in each context. The leading causes of fragmentation at the regional level are: institutional segmentation of the health system, decentralization of health services that fragments the levels of care, the predominance of programs targeting specific diseases, risks and populations (vertical programs) that are not integrated into the health system, the extreme separation of public health services from the provision of personal care, a model of care centered on disease, acute care, and hospital-based treatment, the weak steering role capacity of the health authority, problems with the quantity, quality and allocation of resources, and the financing practices of some international cooperation agencies/donors that promote vertical programs. In general, the sectoral reforms of the eighties and nineties did not consider the unique characteristics of each country. Instead, they tended to adopt standardized models that focused on changes in financing and management, the deregulation of the labor market, decentralization, and the promotion of competition among different health providers and insurers. The reforms also failed to promote essential coordination and synergy among the system’s functions, neglecting their complex inter-relationship and contributing to increased fragmentation. Moreover, population aging, the emergence of chronic diseases and comorbidities, and an increase in citizens’ expectations require more equitable, comprehensive, integrated, and continuous responses on the part of health systems. The achievement of national and international health goals, including the Millennium Development Goals (MDGs), will require greater, more effective investment in health systems. In recent years, the trend in the region has been to introduce policies that promote collaboration among health providers as a way to improve the efficiency of the system and the continuity of care. The region is home to several good practices in the creation of Integrated Health Service Delivery Networks (IHSDNs), especially in countries like Brazil, Canada, Chile, Costa Rica and Cuba, which have traditionally supported the development of networks. Other countries in Latin America and the Caribbean are adopting similar policies to organize their health services. Despite these efforts, addressing fragmentation and providing more equitable, comprehensive, integrated, and continuous health services remain significant challenges for the majority of countries in the Americas. From May to November 2008, PAHO held a series of country consultations based on a draft position paper on IHSDNs to discuss health services fragmentation and strategies to address this problem. The principal achievements of the consultations were confirmation of the urgent need to address the issue of fragmentation and validation of the PAHO IHSDN Initiative. Resolution CD49.R22 on IHSDNs Based on Primary Health Care was adopted during the 49th PAHO Directing Council on October 2, 2009, which also provided new observations for the position paper on IHSDNs. This document is the principal result of these processes. It analyzes the challenge of health services fragmentation, proposes a conceptual and operational framework for understanding IHSDNs, presents public policy instruments and institutional mechanisms to develop networks, and proposes a “road map” for implementing IHSDNs in the countries of the Americas. The purpose of the IHSDN Initiative is to contribute to the development of PHC-based health systems, and thus to health services delivery that is more accessible, equitable, efficient, of higher technical quality, and that better fulfills citizens’ expectations. PAHO considers IHSDNs as one of the principal operational expressions of PHC-based health systems at the health services level, helping to make several of its most essential elements a reality such as universal Concepts, Policy Options and a Road Map for Implementation in the Americas 9 coverage and access, first contact, comprehensive, integrated and continuous care, appropriate care, optimal organization and management, family and community orientation, and intersectoral action, among others. Integrated Health Service Delivery Networks can be defined as “a network of organizations that provides, or makes arrangements to provide, equitable, comprehensive, integrated, and continuous health services to a defined population and is willing to be held accountable for its clinical and economic outcomes and the health status of the population served.” As follows from the previous definition, IHSDNs do not require all of their member health services to be under single ownership. On the contrary, some services can be provided through a variety of contractual arrangements or strategic partnerships in what has been termed “virtual integration.” This characteristic of IHSDNs makes it possible to explore options for complementary services between organizations with different legal status, either public or private. The concept of IHSDNs also provides a suitable framework for collaboration between different countries through efforts such as the “shared services” in the small islands of the Caribbean or services along common borders. Several studies suggest that IHSDNs can improve accessibility to the system, reduce health care fragmentation, improve overall system efficiency, prevent the duplication of infrastructure and services, lower production costs, and better meet people’s needs and expectations. Given the wide range of health system contexts, it is impossible to prescribe a single organizational model for IHSDNs; in fact there are multiple possible models. The public policy objective is to propose a design that meets each system’s specific organizational needs. Despite the diversity of contexts previously noted, the experience of recent years indicates that IHSDNs must possess the following essential attributes for proper performance (grouped according to four principal domains):