1. Edwin Vicente C. Bolastig, MD, MSc Rovanel’s Resort, Tobago
LESSONS LEARNT FROM THE CASE STUDIES ON INTEGRATED HEALTH SERVICES DELIVERY NETWORKS AND VERTICAL PROGRAMMES
Edwin Vicente C. Bolastig, MD, MSc
Consultant, PAHO/WHO
14th September 2010
Rovanel’s Resort, Tobago

2. 2 Presentations:
Case Study on the Integration of HIV/AIDS Services in Trinidad and Tobago into Maternal, Newborn & Child Health Services, as well as Sexual and Reproductive Health Services, including Family Planning (focused on Tobago findings)
Experiences and Lessons Learned from Case Studies in the Region of the Americas

3. Case Study on the Integration of HIV/AIDS Services in Trinidad and Tobago into Maternal, Newborn & Child Health Services, as well as Sexual and Reproductive Health Services, including Family Planning
Edwin Bolastig, Yoko Laurence and Karen Pierre
Funded by:
Pan American Health Organization/ World Health Organization

4. OBJECTIVES OF CASE STUDY
To contribute to the body of work on health services integration
To determine: “how vertical programs and Global Health Initiatives have impacted on the health system, and affected segmentation/fragmentation”

5. TRINIDAD AND TOBAGO: Southernmost Caribbean country
Independence 1962; Republic 1976
Parliamentary democracy
Multi-ethnic population: 1.3M
Oil and gas-based economy
GNI per capita (09):US$ 17,884
10-year GDP growth(99-08): 7.7%
Epidemiologic shift: CNCDs over 60% of deaths

6. CONTEXT First HIV case diagnosed in 1983
8th leading cause of death in 2004
STI-HIV co-infection prevalence rate: 42% (60% M ; 40% F) (Buensuceso, 2008)
HIV/AIDS cause enjoys strong political support
World Bank loan, EU grant, CARICOM PANCAP, government, private sector funding
SOCIAL DRIVERS:
Poverty and unemployment
Gender inequality/domestic violence
High mobility: Caribbean diaspora
Stigma and discrimination
Multiple sex partners/Early initiation
Substance abuse/unprotected sex
(UNAIDS , 2005)
ECONOMIC DRIVERS:
Inequitable income distribution
Sex work due to poverty
Rapid urbanisation
Limited skills and poor socialisation
Sex-oriented tourism
(Camara, CAREC, 2002)

7. BROAD SECTORAL CONTEXT
1986 – National AIDS Programme
1993 – Caribbean Charter on Health Promotion
1996 – Health Sector Reform Programme (HSRP)
National Health Promotion Plan
2001 – Health Promotion Council; Directorate of Health Promotion and Public Health
2004 – National AIDS Coordinating Committee (NACC)
2005 – Vision 2020
2006 – MOH Corporate Plan ( )

8. SEGMENTATION/FRAGMENTATION
Decentralisation of health service delivery to RHAs with the exception of Vertical Programmes and Services
Fragmented human resource management
Dual employment system
Information and medical records management largely manual
Unstructured referral system

9. HIV INTEGRATION INITIATIVES
Integration with Maternal and Child Health - PMTCT
Integration with STI and Family Planning - VCT
Integration with Population Programme - PITC
Integration with Chronic Disease Care
Tobago Health Promotion Clinic (THPC)
Integration of Treatment with Prevention – San Fernando General Hospital
Integration of Information Systems for HIV/AIDS
TERIDA Project

10. Description of the Process of Integration of HIV/AIDS services in Trinidad and Tobago using PAHO’s Framework on Integrated Health Services Delivery Networks (IHSDN)

11. The covered population/territory is defined and there is broad knowledge of its health needs and preferences, which determine the services provided by the system.
HIV Prevalence: 1.5% of Population (generalised epidemic)
Perception that high-risk groups are well-defined but targeted prevention not happening
In Tobago, youths targeted but not MSM or sex workers

12. Tobago Health Promotion Clinic (THPC) – Dr Noel
2. An extensive offer of health facilities and services, which include public health services, health promotion, disease prevention, timely diagnosis and treatment, rehabilitation, and palliative care, all under a single organizational umbrella.
Tobago Health Promotion Clinic (THPC) – Dr Noel
behaviour modification, social services, housing, religious/pastoral services, mental health, substance abuse, mobile services, nutrition, dental referral, etc.

13. A first level of care that acts as the de facto gateway to the system, integrates and coordinates health care, and meets most of the population’s health needs.
Tobago Health Promotion Clinic (THPC) is the gateway into the system

14. 4. Specialist services delivered in the most appropriate place, preferably non-hospital settings.
Pregnant women referred to THPC
Baby treated at paediatric ward in TRH
One (1) HIV specialist in Tobago for adults but none for paediatric care

15. 5. Coordination of care mechanisms exist throughout the entire continuum of services.
A full and integrated coordination of care mechanism is compromised due to:
A lack of feedback to and from TPHC
Ineffective utilisation and training of personnel within organisations.

16. 6. Health care centered on the person, the family, and the community/territory.
Health professionals from the health centres and THPC sometimes go out to the community to do testing via the Mobile Clinics at football games or all-fours clubs.
THPC has a programme that provides support to discordant couples, allowing these couples to have children who eventually turn out to be negative
No prevention programme for at risk families

17. 7. A single, participatory governance system for the entire IDS.
National Strategic Plan for HIV/AIDS is monitored by the NACC under the Office of the Prime Minister), while implementation of the Health Sector Plan is monitored by the Ministry of Health through HACU.
In Tobago, THPC falls under the Tobago House of Assembly (THA); Tobago HIV/AIDS Coordinating Committee (THACC) serves as the link between NACC and THA

18. 8. Integrated management of administrative and clinical support systems.
Disparate administrative and clinical support systems are not managed in an integrated manner
At THPC, administrative and clinical support addressed by some administrative staff but everyone working at clinic can provide support services if necessary

19. 9. Sufficient, competent human resources, committed to the system.
Human resources for the THPC are considered insufficient given the comprehensive nature of the clinic in terms of HIV and chronic disease treatment, which has caused the clinic to grow continuously since its inception.
Only 16 of required staff of 27

20. 10. An integrated information system that links all members of the IDS.
Figure 1: TERIDA –
IT System Diagram
Tobago not included
in pilot project

21. 2 schools of thought in terms of adequacy of financing:
11. Adequate financing and financial incentives aligned with the goals of the system.
2 schools of thought in terms of adequacy of financing:
There is enough funding for HIV/AIDS, the problem is effective utilization and despite huge investments, there is no reduction of HIV in the general population.
Financing could never be enough: as progress is made in diagnosis and treatment, new techniques, equipment and drugs emerge in the market.

22. 12. Broad intersectoral action.
Collaboration between THPC and support groups like TAS, OASIS and others
THACC is known for engaging the community through the village councils in the implementation of HIV-related projects.
Corporate sponsorships but discrimination happens in the workplace

23. EMERGING MODELS Three (3) Emerging Models of Integration:
Standalone outpatient HIV/AIDS clinic integrated with chronic disease care (Tobago Health Promotion Clinic)
Hospital-based HIV/AIDS testing and treatment centres – adult & paediatric (San Fernando General Hospital)
Satellite network of multi-tiered hospital based and outpatient health facilities

24. ADVANTAGES/STRENGTHS
MODEL 1 – Stand Alone
ADVANTAGES/STRENGTHS
GAPS/WEAKNESSES
By associating HIV/AIDS with other chronic diseases, stigma and discrimination may be minimised
Unique branding strategy associating comprehensive approach with quality care
Well-organised manual record-keeping transitioning to a paperless information system
Multi-tasking of health workers
Triaging according to purpose of visit (counselling and testing, pick-up of ARVs, consults, etc.) to avoid long queues and waiting times
Community outreach activities (home visits) ensures good follow-up/ return rates
Weak linkage with health centres doing counselling and testing
Referrals have to be made to the Scarborough General Hospital for treatment of paediatric patients and to the OB/GYN Ward for pregnant women
Inconspicuous location – not all potential clients are aware of the clinic site (Conversely, could be an advantage too)

25. MODEL 2 – Hospital Based Testing and Treatment
ADVANTAGES/STRENGTHS
GAPS/WEAKNESSES
Simulates “one-stop shop” for services (STI, HIV/AIDS testing, counselling and treatment, maternal and child care, etc.) in a single health facility/ compound
Weak community outreach services
Link to family planning services missing
Hospital-based care is known to be generally more expensive than out-patient care

26. MODEL 3 – Multi-tiered Satellite Network
ADVANTAGES/STRENGTHS
GAPS/WEAKNESSES
“Hand-holding” approach to referral of patients to other health facilities
Assurance of a wide range of services
Relatively good feedback being received from facilities where patients were referred to
Patients being lost in the process of referring to another health facility
Patients being lost to follow-up
Longer time spent in securing appointments and attending clinics
Travel and opportunity costs of attending multiple clinic schedules

27. FINANCING – Total TTD 253.5 million
3-fold increase in prevention targeted to general population
Funding for PMTCT declined but remained a success
Substantial increases in treatment due to ARV medications
Programme mgt, coordination & eval’n increased
Government expenditures exceeded commitments
Private sector and int’l organisations played some role
1 USD = 6.29 TTD

28. BENEFITS
Programmes – institutionalisation of PMTCT; integration of VCT with SRH; free ARVs
Resources - high levels of funding for HIV/AIDS also used for MCH, STIs and FP
Processes - shift from a programme approach to institutionalisation of interventions
Intermediate products – build capacity of committed health personnel
Outcomes – increased HIV testing among mothers; improved efficiency in some areas; community outreach

29. TWO SCHOOLS OF THOUGHT ON INTEGRATION:
Strengthening of services as pre-requisite to integration vs. Integration as means to improve services
From all of the information gathered, two opposing schools of thought on the integration process were uncovered:
1- Integration should not happen unless individual vertical services are strengthened so that the strength of one programme is not “diluted” by the weaknesses in other services or programmes.
2- Integration will facilitate the process of strengthening the weaker services or programmes by building upon the strengths of the stronger services or programmes.

30. LESSONS LEARNT Facilitating factors:
Role of advocates and champions in the health system
Perception of strong political support from government
Health promotion (high risk groups and wider population)
Service delivery decentralisation (RHAs)
Increased resources for HIV/AIDS
Expanded role of civil society – “knowledge broker”
including mass media campaigns targets both high-risk groups and the wider population
Increasing role of RHAs in carrying out the decentralised mandate of delivering services closer to where their target populations are  success of the rapid testing programme, particularly in the NWRHA
The mobilisation of increased resources for HIV/AIDS in improving infrastructure conducive to the delivery of services
The role of Civil Society expanded to include “knowledge-brokering”  brokering information not only between patients and doctors, but also with a wider network of support systems

31. LESSONS LEARNT Hindering Factors: Structural and support services
– inadequate infrastructure, human resource shortages, weak reporting and referral systems
Socio-cultural
– breach of confidentiality, S&D, territorialism, lack of accountability
Policy and legal environment
– lacks policy framework for zero tolerance to S&D, non-adherence to protocols/SOPs
Structural and support services:
Inadequate infrastructure, human resource limitations in terms of skill and training for testing and counselling, and inadequate information technology and data capture systems
Human resource underperformance, shortages, high turnover and inadequate training  recurrent hindrance to integration
Weak reporting systems result in double counting of cases and an inefficient use of resources.
Insufficient follow-on services
Support systems for HIV services that do not operate at full capacity
Physical facilities, in terms of portability of patient records; ease of flow of services and patients; and geographic location, need improvement
Socio-cultural:
Concerns about breach of confidentiality due to unethical distribution of private information by health workers
Insufficient client support of services and programmes
Stigma and discrimination, domestic abuse, lack of accountability, a culture of tolerance for underperformance and ‘turfism’.
Policy and legal environment:
An absence of or a lack of adherence to protocols, guidelines, SOPs or other policy instruments
e.g. mechanism needed to force the private sector to take-up the policy
Anecdotal incidents of discrimination of PLWHA by their employers, forcing them to change jobs more often than non-HIV positive individuals or HIV positive individuals whose status is unknown.

32. AREAS FOR IMPROVEMENT Socio-cultural Health workforce Service delivery
Systems interventions
Policy and legal environment

33. CONCLUSIONS
Resources for HIV/AIDS supported integration of HIV services with other health programmes such as Maternal and Child Health
GHIs did not seem to have undermined national planning and policy development process
Integration process aligned with national priorities, along existing mechanisms for coordination

34. Lessons Learned in the Region of the Americas: Case Studies
Experiences and
Lessons Learned in the Region of the Americas:
Case Studies
Regional Advisory Meeting:
Integrated Health Services Networks and Vertical Programs
Cusco, Peru
11 and 12 November 2009
Hernán Montenegro and Caroline Ramagem
Area of Health Systems and Services
PAHO/WHO

35. Integration Initiatives in LAC
Country
Initiative
Argentina
Law creating the Integrated Federal Health System
Bolivia
Municipal Intercultural Family and Community Health Networks and Network of Services
Brazil
Better Health: The Right of All
Chile
Health Care Networks Based on Primary Care
El Salvador
Law creating the National Health System
Guatemala
Coordinated Health Care Model
Mexico
Functional Integration of the Health System
Peru
Guidelines for forming networks
Dominican Republic
Regional Health Services Network Model
Trinidad and Tobago
Experience of the Eastern Regional Health Authority
Uruguay
Integrated National Health System
Venezuela
Health Network of the Metropolitan District of Caracas

36. Summary of Case Studies Lima Workshop, 9 November 2009
Country
Type of Case
Integrated health services networks
(2 topical + 3 general = 5)
Integration of vertical programs (6)
Brazil
Care for women and children: “Mãe Curitibana” (Curitiba, Paraná)
Urgent/emergency care (Northern Macroregion, Minas Gerais)
HIV/AIDS (National)
Chile
Ñuble Health Service
Metropolitan Health Services
Children: “Chile Grows With You” (National)
Guatemala
Ministry of Public Health and Social Welfare and Guatemalan Social Security Institute (Department of Escuintla)
Colombia
Tuberculosis (National)
Peru
Dominican Republic
Trinidad and Tobago

37. FACILITATING FACTORS AND BARRIERS

38. FACILITATING FACTORS Political commitment and backing
Availability of financial resources
Leadership of health authorities and service managers
Decentralization and flexibility of local management
Alignment of financial and non-financial incentives
Culture of collaboration and teamwork
Active participation of stakeholders

39. STRUCTURAL BARRIERS Segmentation and weakness of health systems
Reforms of the 1980s and 1990s:
Privatization of insurance
Differentiated service portfolios
Provider competition
Diversification and instability of labor regimes
Regressive cost-recovery schemes

40. STRUCTURAL BARRIERS Powerful opposing Interest groups:
Specialists and super-specialists
Private insurers and social security
Pharmaceutical industry, supply industry, etc.
External financing modalities (Global Health Initiatives)

41. NON-STRUCTURAL BARRIERS
Deficiencies in information, monitoring, and evaluation systems
Management weaknesses

43. Thank you!