4. U.S.
Global
Health
Initiative
GHI Integration Workgroup
• USG Interagency workgroups for all GHI Principles
formed in Aug 2012 (members from USAID, OGAC and
CDC).
• Tasked to develop guidance for countries to use to
measure and evaluate the principles
• Deliverables: results framework, global indicators and
illustrative indicators
• Integration workgroup provided with funding to develop a
―learning agenda‖ to further the evidence base on
integrated service delivery
• In process of collecting feedback on products from
countries, implementing partners and other stakeholders
5. U.S.
Global
Health
Initiative
GHI Integration Progress
• Definition of Integration:
….The organization, coordination, and management of
multiple activities and resources to ensure the delivery of
more efficient and coherent services in relation to cost,
output, impact, and use…. )
• Summarized findings from USAID Cochrane Reviews
2010
• Evidence on Integration is limited by lack of rigorous
studies
(operational feasibility of measuring is complex-
most services are along a continuum of integration)
• Developing Integration Scoping Tool
• Developing illustrative integration measures – by core
outcomes
6. U.S.
Global
Health
Initiative
Key Issues Considered for Developing the Results
Framework, Indicators and Learning Agenda
• Integration is not an ―intervention‖- RF not typical so
inputs, outputs and outcomes vary by country and
context
• Significant overlap with other principles, e.g. HSS &
gender; integration best conceived as an
approach/lens
• Results Framework and Indicators should go beyond
specific service delivery interventions (e.g. Nutrition
and HIV, MCH/FP, TB/HIV)
• Learning agenda should focus on what countries
need to make strategic decisions about scaling up
integration
– provide evidence on how and when does integration
affect key outcomes
– what integration models work and under what
conditions?
7. Outcomes of Integration contribute to GHI targets for HIV/AIDS, TB, Malaria,
NTDs, Maternal Mortality, Family Planning, Child Mortality and Nutrition
Coherent Service Integration*
• Integrated Manuals, guides / job aids on site
• Services organized within facilities to meet different client needs e.g.
single client (FP & ANC) or multiple clients (e.g. mothers & infants)
• Linkages across facility-community based care ; Effective referrals
• Minimum package of essential services available
• Efforts to support a continuum of care and ensure principle of “no
missed opportunity in service provision”
Policy and Governance
Demand Creation and
Healthy Behaviors
Planning and
Management
Health System Functions
• Policy Makers, Managers and
Donors support integration
• Financing and resource allocation
to foster integration
• Decentralized functions
• Policy and Guidelines for Integrated
Service Delivery
• HMIS-Integrate surveillance, M&E
and Information Systems
• HRH- Adapt HR functions,
management systems and tools to
foster integration
• Cross training and task shifting
• Medical Tech- Laboratory and
logistics systems are linked
When interventions for populations
overlap;:
• Joint Planning for multiple programs
• Consolidate administration
management, and staff across
programs for smart integration
• Pool/share resources across disease
specific programs
• Integrate Behavior Change
communication campaigns
• Health behaviors are
promoted in combination e.g.
Nutrition and FP
• Barriers to health seeking are
addressed in coordinated and
integrated fashion
*Service Integration of proven
efficacious interventions e.g.
• Preventing Mother-to-Child
Transmission (PMTCT)
Coverage and Access Acceptability
“Added value” of Smart Integration ( Benefits/Results)
• Improved availability of
services e.g. one stop shop
• Increased coverage of
effective interventions
• Expanded access of
services per client contact
• Improved client satisfaction
• More family centered care
• Improved retention in care
• Improved health seeking
• behaviors
• Community engagement
• Cost savings/Improved
resource use
• Reduced duplication of
efforts
• Improved functioning of
health system
• Increased readiness of
services to meet client needs
• Appropriate follow up
• Reduced missed
opportunities at high volume
contact points
Responsiveness / Quality Efficiency Uptake (Use)
• Improved uptake of
integrated services
• Improved use of services
along the continuum
• Improved patient care- e.g.
ART initiation, EID etc.
Integration Inputs
Integration Outcomes
Health Outcomes
SustainedImpact Sustained Improvements in Health Status
Integration Outputs
8. U.S.
Global
Health
Initiative
GHI Indicators
• The USG GHI Integration TWG tasked with
developing up to 3 Global Indicators that
map to the Integration RF
• Illustrative indicators are a resource for
countries to monitor their integration efforts at
the country level and do not need to be
reported
9. U.S.
Global
Health
Initiative
Learning Agenda Overview
Goal: to assist Missions and host countries to plan,
design, monitor and evaluate integrated services
Obj 1: understand current state of integrated
service delivery models in a number of countries
and the drivers & factors facilitating choice of model
and interventions.
Obj 2: understand how well interventions map to
RF and document strengths, weaknesses, gaps of
M&E systems.
Obj 3: identify country specific eval opportunities
and study designs (for phase 2)
Year 1 funding provided to MEASURE Evaluation
(Year 2 TBD).
10. U.S.
Global
Health
Initiative
Learning Agenda—Question 1
What is the current experience of countries in
implementing integrated health services?
Identify ―best bets, best buys‖
– Which services when integrated or bundled and under
what circumstances seem to be the most efficient and
which are better left not integrated?
– What types of models of integrated services (e.g. one
stop shop model; co-location of services; referral models)
are appropriate in various contexts and for different types
of service delivery platforms (e.g. community-based
services; clinic services)?
– Is there a ―tipping point‖ where adding extra services
might actually be more harmful than beneficial?
Approach: Conduct survey and case studies in a sample of GHI
countries to document their experience implementing integrated
services over the last 3-4 years.
11. U.S.
Global
Health
Initiative
Learning Agenda—Question 2
What is the value-added of integrated service delivery
compared with community standards of care?
Outcomes to measure:
• Coverage and access
• Client acceptability
• Responsiveness and quality
• Efficiency
• Service use and uptake
• Equity
Approach: Case studies and impact eval in
selected countries.
12. U.S.
Global
Health
Initiative
Contact Information:
• Kristin Saarlas, ScD, MPH
Evaluation Advisor
Office of Policy, Programs, and Planning (P3)
Bureau for Global Health, USAID/Washington
mobile: 571-345-5463; email: ksaarlas@usaid.gov
• Rushna Ravji, MD, MPH, MS
Health Team Leader, Asia and the Middle East
Bureau for Global Health, USAID/Washington
mobile: 202-538-3358; email: rravji@usaid.gov
Not sure how many people are already familiar with GHI, brief overviewVarious WG formed around the themes to identify programmatic themes, address M&E issues. Our work focuses on integration.
Here is the context, this may look familiar.
Keep this slide.Working to develop guidance, RF, indicators and in our group, we have specific learning agenda for this topic.
Integration paper is on the GHI website, encourage people to check it out.Integration Scoping Tool – details are in the paper. Table 1 is in this paper, helps to get people to think through where they are with integration in their country. How far along is the country, without judgment/value placed on how questions are answered. Mainly to get programs/missions thinking about possibility of integration, “walk through” integration issues. Not yet implemented in a lot of places and there may efforts to implement/”pilot” in the future. “Readiness to integrate”. Please check it out. Series of questions under different domains (ex, policy) and questions about resources/consolidation/management of integrated service delivery (ex, facility based, community based services).
Not an intervention – not trying to identify the results of a specific intervention and how input/process/outputs lead to outcomes. Integration is a means of service delivery for interventions we may already know about in terms of results. So RF looks very different. Learning agenda purpose is to support countries in making decisions about which services should be integrated, how to assess opportunities for integration and identify promising approaches.
Coherent service integration addresses systems/policy.Added value of integration is in purple text – these outcomes are thought to be broadly applicable to any context/country.Very open to feedback.
A lot of pushback from MERG last week about recommending global indicators. REVISE – looking at potential to develop indicators and working with different groups to see what is feasible (ex, UNAIDS MERG).There is the possibilityUSG Missions will report Global indicators to Washington as part of routine reporting once indicators are field-tested and finalized.Indicator development process:Indicators are guided by the Integration Results Framework finalized in October 2012January 2013: Review of grey literature and indicator databases/compendiums to identify existing indicators/metrics for integrationFeb 2013: Update to and input from M&E stakeholder’s during the BGH CA’s M&E TWG meetingMarch 2013: Streamlining, prioritizing and crafting indicator language to develop draft list of global and illustrative indicators for field input
Potential countries include:EthiopiaKenyaTanzaniaRwandaMozambiqueSenegalGhanaLiberiaCambodiaPakistanIndonesiaNepalBangledeshCountries selected because they are GHI programs,have either current or new integration projects—represent a range of progress and models. Most are integrating with HIV but not all