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PUBLIC
HEALTH
FOUNDATION
OF INDIA
IDENTIFYING OPERATIONAL PATHWAYS FOR
INTEGRATING NATIONAL DISEASE CONTROL PROGRAMMES
WITHIN THE FRAMEWORK OF UNIVERSAL HEALTH COVERAGE
Executive Summary
‘Identifying Operational Pathways
for Integrating National Disease Control
Programmes within the Framework of
Universal Health Coverage’
Executive Summary
EXECUTIVE SUMMARY
Key Recommendations from Identified
Potential Pathways to Integration:
I. Establish the National Health Mission (NHM) as a pan-lndian institutional
platform for facilitating integration among the various disease control programmes.
Since programmes already fall under the ambit of the NHM in terms of common
funding, the NHM could potentially serve as a common element in facilitating
programme integration at various levels and with the larger health system
framework assuring continuity of care from primary to tertiary level services;
2.
Reduce Centre-State dichotomy by accommodating State-centred
priorities; Involve States during policy making and programme planning processes
in coordination with the Centre. States should be allowed enough design
and operational flexibility in the design and delivery of national health
programmes. State ownership is an important mechanism in determining under
what circumstances vertical and horizontal programmes have a role in health
systems and when implementing and managing integrated services;
3.
Encourage and evolve strong political leadership at regional and central
levels who understand and appreciate the value of integration;recognize
champions among bureaucrats and implementers to facilitate funding and create
conducive environments for better integration of programme components,
promote task sharing and joint capacity building and initiate integrated delivery
of services;
4.
Develop an autonomous National Health Regulatory and Development
Authority (NHRDA) to set quality assurance parameters and enforce monitoring
and joint evaluation mechanisms in integrated systems;
5.
Foster coordination with different stakeholders including traditional
medicine providers like AYUSH to create an enabling environment and a
shared ideology in making programmes function in an integrated manner;
6.
Identify areas of commonality between programmes (of similar
epidemiological and clinical disease profiles) for appropriate integration
of programme components. Common or overlapping elements of compatible
programmes will lend themselves better to integration at policy, procedural and
service delivery levels;
7. Make Proactive Data Sharing mandatory among National Health
Programmes. Strengthen and scale up HMIS components by investing in IT
infrastructure and platforms to expand scope of data sharing between programmes
and simplify data entry procedures, invest in training of programme
administrators and field staff in monitoring data quality, elimination of redundant
data and use of data to improve programme quality, performance and coverage;
Qj 3
Identifying Operational Pathways for Integrating National Disease Control Programmes within
The Framework of Universal Health Coverage
8. Optimize and rationalize human resources for effective integrated
delivery of services through calibrated joint training of programme personnel (to
overcome attitudinal barriers around in the integration processes), recruitment
pools and joint skill building across programmes. Create and sustain an exclusive
professional public health programme administrative cadre trained to manage
integrated programme networks;
9. Establish public-private sector collaboration at equal terms without either
sector wielding undue authority. Selective integration of the private sector with
public health programmes in areas of management, services delivery, quality
control, supply chain logistics, human resource training and infrastructure with
contractually bound monitoring mechanisms;
10. Initiate policy level reforms for National Programmesfor Human Resource
recruitment, remuneration, career trajectory, incentives, joint guidelines, joint
capacity building and roles/responsibilities. Pilot integrated pooled recruitment
and training amongst the larger programmes;
I I. Empower programme implementers at State and Central levels by
delegating powers and responsibilities appropriately; giving implementers a sense
of ownership of programmes at various levels motivating them and creating an
environment for integration;
12. Encourage wider inter-sectoral convergence to integrate social determinants
of health such as water & sanitation, infrastructure, and environment to achieve
systems level integration.
4
‘Identifying Operational Pathways for
Integrating National Disease Control
Programmes within the Framework of
Universal Health Coverage’
Background
Universal Health Coverage (UHC) is a widely shared
global health agenda. Over the last two decades
healthcare demands across the world have risen steadily
against a backdrop of increasingly limited resources.
Health expenditures now regularly outstrip growth in
gross domestic product (GDP) across many countries,
providing a compelling need for health systems reform
and evaluation.
The UHC policy for India first documented in the 12th
Five-Year Plan aims to meet the healthcare needs of
its population through a publicly financed system.'
This effort however maybe hindered by a weak public
health system. India’s current mixed health sector
presents numerous, diverse and highly interactive
agents. While the public system is hampered by overt
centralization, rigid planning and poor management,
the mostly unregulated private health sector involves
both formal and informal providers competing with
government providers for secondary and tertiary care
across the country.*2 The National health programmes
nested within this system have patterns of interaction
that are dynamic, non-linear and depend on multi-level
networks of actors. Hence there was need to examine
Integration both at the systems and programmatic
levels.
Changing health priorities reflected in newer
epidemiological transitions of ongoing chronic and
resurgent infectious diseases, new technologies and
treatments, and financial constraints have led healthcare
systems around the world to seek fundamental changes
in their design wherein integration strategies form
major feature of reform efforts. According to Atun et al
when viewed in the context of health systems the terms
horizontal and vertical integration are widely used in
health service delivery with each type describing a range
of phenomena.3 However, it appears that in practice,
the dichotomy between them is not all that rigid,
and the extent of verticality or horizontal integration
varies between and within programmes. More recent
debates around the benefits of integrating targeted
health programmes have evolved beyond the vertical
horizontal divide and presents scenarios where vertical
and horizontal systems can complement each other
while forging selective linkages in areas of financing.
human resources and primary health services.
If the country is to consider developing a larger
framework for UHC it is important to take into
account the nature and distribution of existing health
programmes. While the 12th Five Year Plan advocated
the integration of national health programmes it did not
'Planning Commission. Government of India-Twelfth Fiver Year Plan 2012-2017.Social Sectors Volume 3. 2012.
Available at: http://l2thplan.gov.in/
2De Costa A, Johansson E, Diwan V K. Barriers of mistrust: public and private health sectors perceptions of each other in Madhya Pradesh.
India. Qual Health Res 2008; 18: 756-766.
3Atun, R, Jongh d T, Secci, F, Ohiri, K and Adeyi, O. Integration of targeted health interventions into health systems: a conceptual framework
for analysis; Health Policy and Planning; 2010: 25: pp 104-1 I I
“World Health Organization. The World Health Report: The Road to Universal Coverage. Geneva, Switzerland: World Health Organization;
2010
5
Identifying Operational Pathways for Integrating National Disease Control Programmes within
The Framework of Universal Health Coverage
specify the scope and nature of integration or the levels
Methods
and depth of interaction between programmes. Most
vertical programmes in the country were initialized in
response to addressing and containing specific disease
15 national
health programmes (disease control and promotive
programmes), 8 of which currently have varying levels
of ‘integration’ with the National Health Mission (N HM)
addressing point-of-entry primary healthcare delivery.
However, many interventions remain fragmented
due to the vertical nature of programmes resulting in
replication of services and an absence of task-shifting
and task-sharing which would otherwise maximize
limited resources. The World Health Organization
(WHO) estimates that 20-40% of health budgets
globally are wasted due to health system inefficiencies
that include demotivated health workers, service
duplication, and inappropriate or overuse of medicines
and technologies.4
burdens across populations. India has
2.
3.
6
stakeholders as well as explore potential pathways for
further ’integration’ within and amongst programmes.
The study was carried out in two phases as detailed in
Figure I and involved systematic literature review and
evidence synthesis followed by primary data collection.
The mixed-methods design involved the collection of
qualitative information in the form of semi-structured
interviews and focus group discussions followed by
quantitative data collection through the administration
of a Likert Scale questionnaire as concurrent phases
in the study. Six states were selected for primary data
collection based on the NFHS-III (2005-2006) health
indicators and their geographic locations so as to
capture the national perspective
High Health Indicator States - Kerala, Tamil Nadu
To assess the perceived level of integration existing
among disease control programmes currently
under the NHM in India.
Moderate Health Indicator States - Gujarat,
Karnataka
•
To identify operational pathways for gradually
integrating preventive (disease control) and
promotive programmes into the UHC mandate;
Low Health Indicator States - Assam, Madhya
Pradesh
selected from both the Center and six Indian States,
To define 'integration processes’ at the Centre and
State levels with reference to;
involving policy makers, programme implementers,
development partners and civil society.
Potential pathways of integration/
accommodation of various programmes;
•
Levels of integration;
•
Types of integration;
•
Role of the National Health Regulatory
and Development Authority (NHRDA) in the
integrative process;
4
perceptions of programme ‘integration’ among various
•
•
4.
Health Foundation of India, New Delhi with the support
of the Royal Norwegian Embassy (RNE) to capture
•
Objectives of the Study
I.
A mixed methods study was conducted by the Public
Identify opportunities and barriers in the integrative
processes.
Sampling was purposive with
128 key informants
Phase I of the study preceded field data collection and
involved a comprehensive desk review and evidence
synthesis that had two focus areas:
I.
The first systematic review was conducted to
arrive at a more nuanced and operationally relevant
definition of integration and its levels and;
2.
A second review concentrated on’mapping” i.e.
documenting the history, architecture, and networks
of preventive and promotive programmes at both
World Health Organization. The World Health Report: The Road to Universal Coverage. Geneva. Switzerland: World Health
Organization: 2010
EXECUTIVE SUMMARY
Figure I: Schematic Diagram of Methodology
OUTPUT
Definition of
Integration;
Scale: Levels of
Integration
Levels of
Integration among
National Disease
Control Programs
Validated Tool
Interview Transcripts
Report
central and state levels. The gaps generated from
the desk review were filled by consultations with
experts in the related disease control programme.
Also, it was important to document fragmentation
at the state level resulting from the establishment
of state societies for preventive programmes.
Findings
developing a conceptual framework for
programme integration to address our study objectives,
the multiple interpretations around the term
'integration’ at the programmatic and system levels
were taken into consideration. For this review the
concept and vocabulary of integration were examined
across 3 areas:
While
I.
Functional and operational definitions of the term
or activity of Integration;
2.
Dimensions of Integration - Measuring
Programme Centered vs Organizationally
Centered vs Health System Centered aspects of
integration;
3.
Degrees of Integration - Evaluations of the range
and depth of integration between and among
programmes and the overall health system.
Programme integration can resolve health system
inefficiencies and forms a crucial component in
the overall implementation of UHC. However, a
universally accepted definition of integration did
not exist for vertical disease control programmes.
Empirical literature often conceptualizes programme
integration as being horizontal and/or vertical in nature,
with disease control programmes commonly viewed
as vertical structures.56-5
7 While integration is often
6
associated with service delivery, yet, linkages of health
programmes between or within systems are less widely
discussed. In the course of our review it emerged
that the term ‘integration’ was used to describe
a range of processes that included organizational
arrangements
and
activities
between
individual
agencies, across programme structures or components
and involved multiple programme domains (such as
policy.advocacy, administration, service provision and
human resources).8 The discordance in definitions of
5
Atun R, Bennett S, Duran A: When do vertical (stand-alone) programmes have a place in health systems? World Health Organization
6
Atun, R, Jongh d T, Secci, F, Ohiri, K and Adeyi, O. Integration of targeted health interventions into health systems' a conceptual framework
7
Williams, Paul; Sullivan, Helen. Faces of integration. International journal of Integrated Care, [S.l ], dec. 2009.ISSN 1568-4156. Available ar
Copenhagen, Denmark; 2008.
for analysis; Health Policy and Planning; 2010: 25: pp 104-1 I I
<http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3AI 0-1 -100751 /1016>. Date accessed: 06 Jul. 2014
7
Th " F™ Ope.rati.°inial Pa'hWayS for '"toting National Disease Control Programmes within
The Framework of Universal Health Coverage
integration has led to the concept being used loosely
service delivery. This definition was the slightly modified
at policy, implementation and operational levels, with
sub-categories of integration such as coordination,
for the Indian disease control programme context with
collaboration and cooperation used inter-changeably.
While health systems combine both non-integrated and
integrated interventions, the purpose, nature and extent
of integration vary enormously among organizations
and programmes. Seldom are interventions wholly
un-integrated or fully integrated into health system
functions. The Indian health system presents a scenario
populated by diverse sets of actors, organizations and
service delivery mechanisms. The large public sector
which includes the National Health Programmes is
comprised of agencies and institutions targeted at
both individual and population based health services,
while the largely entrepreneurial private health sector
is mostly person-focussed and includes non-forprofit organizations and informal care providers. An
operational definition of Integration that relates to this
the addition of six programme-specific components
that included: g) Policy h) Health Information
Systems i) Drugs & Logistics j) Management/
Administration k) Human Resources and I) Health
Communication.
Evolving from various empirical conceptualizations
of degrees of integration, a spectrum of integration
eventually emerged (between and within programmes
and the health system), that ranged from non-integration
or segregation on one end to complete consolidation or
merger on the other. Based on this continuum, levels
of integration as applicable to the Indian Health System
were subsequently conceived. Since our study focused
on potential pathways of integration for National Disease
Control Programmes, we subsequently identified
programmes as independent entities that possessed
complex system of providers would have to address
characteristic structural (organizational structure,
funding, infrastructure) and functional elements
various levels and types of actors and their engagement.
(planning, procurement, data management).",l2
into account
diverse interpretations of
‘integration’ from assorted
literature, a functional
definition of integration most relevant to disease
and depth of integration within programmes, a five-level
Taking
control programmes in India was subsequently selected
for the study from Atun et.al (2010, 2008)5,6 and Atun
and Menabde (2008)’ where integration is defined
Using these various elements to better clarify the extent
scale (Table I) was developed to describe the depth of
integration based on both, policy and functional linkages
within and/or between programmes. According to this
scale, an increasing number of programme components
as: the extent, pattern, rate of adoption and
involved correlates with increasing levels of integration.
eventual assimilation of health interventions/
programmes into each of the critical functions
Within the continuum created, we have attempted to
of a health system, which includes, inter alia: a)
measure the degree of integration occurring according
to number of programme components involved.
Governance b) Financing c) Planning d) Service
For example the programme components we have
Delivery e) Monitoring and Evaluation f) Demand
included in our scale are policy, management, finance,
operations, and architecture. In our table and scale as
two programmes integrate to join more components,
Generation.8
*10*12
An 'intervention' in this context refers
to combinations of technologies, inputs into service
delivery, organizational changes and modifications in
processes related to decision making, planning, and
8
their defined level of integration increases across this
continuum.
Newhouse Robin R Mills ME. Johantgen M. PronovostPJ.. Is there a relationship between service integration and differentiation and patient
outcomes?. International Journal of Integrated Care. [S.I.J.nov. 2003. ISSN 1568-4156. Available at: <http://www.ijic.org/index.php/ijic/
article/view/URN%3ANBN%3ANL%3AUI%3AIO-l-IOO333>. Date accessed: 23 Jul. 2014.
’ Ibid
10 Atun R, Ohiri K Adeyi O: Integration of Health Systems and Priority Health. Nutrition and Population Interventions: A Framework
for Analysis and Policy Choices. In Health. Nutrition and Population Discussion Paper: The World Bank. Washington D.C., USA; 2008
Retrieved from http://bvsms.saude.gov.br/bvs/publicacoes/Population_Discussion_Papenp
" Shigayeva, A. et al. (2010) Health systems, communicable diseases and integration. Health Policy and Planning. 25. pp: 14-120.
12 WHO(I996). Integration of Health Care Delivery: Report of a WHO Study <Group. WHO Technical Report Series- 861.Geneva. Accessed
on September 20, 2012. Retrieved from http://whqlibdoc.who.int/trs/VV
8■
_
_
-P
EXECUTIVE SUMMARY
Table I: Five levels of Integration
Name
Definition
Components Involved
Accommodation
Programs communicate and develop
a working agreement to align their
activities
Primarily at the Policy
level, Management
2
Joint Funding
Programs share the disbursement,
management, and accounting of funds
Policy, Some
Management structures, Finance
3
Joint Programming or
Joint Operations
Resources (such as staff, infrastructure)
are pooled together
Policy, Management,
Finance, Operations
4
Consolidation
Partial merger where one or more
components of a program are fused
Architecture, Policy.
Management, Finance,
Operations
5
Merger
Complete fusion of two or more
programs to a common structure
Architecture, Policy.
Management, Finance,
Operations
Level
The situation analysis of 15 national health programmes
(level 3) in joint operations activities seen taking place
(disease
control
and
promotive programmes)
documented existing levels of integration among and
between RCH and the School Health programme as well
as NVBDCP and IDSR Programmes like NACP involve
between programmes. Programme components
were assessed at central, state and district levels
(and included policy, management, human resources,
the participation of almost 2000 NGOs in programme
implementation activities at the state, and district levels,
in order to increase programme reach among highly
infrastructure, service delivery, finance, logistics, M &
stigmatized and marginalized target populations.
E, and information education and communication (IEC).
Service delivery at the block level was also included. A
series of colour-coded matrix charts were subsequently
developed by applying the integration scale developed
earlier (Table I) to programme level data generated
by the mapping process that would graphically portray
the nature and level of current relationships between
Figure 3, the mapping of Information, Education and
Communication program components at State and
Block level reveal a common IEC system that shows
integration at level 5 that indicates a ‘merger’ implying
incorporation of two or more programmes to form
common IEC programmatic activities across almost all
individual programmes.
the programmes with the exception of the School Health
Programme which is still at the consolidation level (level
The information generated by this analysis assisted
4)
in developing and designing our tool for primary
data
collection
accordingly.
Examples
of existing
levels of integration taking program components like
management and MIS are depicted in Figures 2 and 3
below
integration. Indicating that at this component level
the School Health Programme remains un-aligned with
the other national programmes.
Overall information management is largely vertical
along India's various National Health and Disease
Control
Programmes.
Varying
sources
of
health
Figure 2, below shows the status of integration
information have resulted in data being collected from
‘management and administrative’ programme
components operational at the Centre and State
data begins at the Sub-Centre level, which is the first
of
both central and the state level agencies. The flow of
level between and among programmes. Between the
point of contact for primary care. Monthly reports
RCH and RNTCR programmes integrative activities
corresponding to the first level of integration (i.e.
from Sub Centres are then dispatched to the Primary
accommodation) was observed. Similarly integration
District level headquarters. Data collated at the district
at the accommodation level was also seen existing
is finally sent to State authorities. However, in addition
between RNTCR UIP and the NVBDCR However
to these routine health information flows, national
integration activities were appreciated at a higher scale
health programmes like Malaria, TB, AIDS and Leprosy
Health Centre where data is aggregated and sent to
Identifying Operational Pathways for Integrating National Disease Control Programmes within
The Framework of Universal Health Coverage
Figure 2: Component: Management: Centre & State Operation
NVBDCP
UIP
RNTCP
RCH
NPCDCS
NLEP
IDSP
NPCB
NPPCD
NMHP
NACP
School
NIDDCP
NTCP
Health
3
1
RCH
RNTC
1
1
1
UIP
NVB
3
DTP
IDSP
NLEP
NPCD
CS
NPCB
MPPCD
Scho
NACP
NMH
P
NIDD
CP
NTCP
|
Level 1:
|
Accommodation: Programs communicate and develop a working agreement to align
their activities; Communicate with each other during planning, policy making.
Level 3:
|
j
Joint operations: Pool resources and jointly carry out interventions.
Figure 3: Component: Management Information System (MIS): All levels
1
RCH
RNTCP
UIP
NVBDC
P
IDSP
NLEP
NPCDC
S
NPCB
NPPCD School
Health
Nft/IHP
NACP
NIDDC
NTCP
1
RCH
1
1
1
RNTCP
1
UIP
1
NVBDC
IDSP
NLEP
NPCDC
S
NPCB
NPPCD
School
Health
1
NACP
NMHP
NIDDC
NTCP
|
|
Level 1:
Accommodation: Programs communicate and develop a working agreement to align
their activities: Referral, sharing of information.
|
Level 4:
Consolidation: Partial merger where one or more components of a program are
amalgamated; Common MIS system._______________________ ____ _________________
LLM
Box 1: Colour index for schematic grids on programme integration
Level 1
Accommodation: Programmes communicate and develop a working agreement to align their activities.
Level 2
Joint Funding: Two or more programmes share the disbursement, management,and accounting of funds.
Level 3
Joint Operations/Joint Programming: Resources are pooled together to run operations that meet certain common objectives.
Level 4
Consolidation: A partial merger where one or more components of a programme are amalgamated.
Level 5
Merger: Incorporation of two or more programmes to form a new/common structure.
The, blank areas in the matrix indicates an absence integration taking place or lack of information on integrative activities at specific levels
amongst the mapped programmes.
have their own health information systems and report
directly to the state health programme offices, often
bypassing district level reporting. Currently, different
information subsystems rarely interact or are used by
disease-specific programmes in different ways resulting
in variable data originating different information sources
with no standard system for ensuring overall consistency
and coherent reporting.
majority of the respondents emphasized integrated
service delivery within the community that would
create a continuum of preventive and curative services
delivered at a common or integrative point of care. In
this case, the primary health centre would form the
nucleus of this integrated care delivery system which
would be staffed with shared human resources.
A common vision that emerged across all states
The Qualitative Study component covered nine
and respondent groups was that service providers
broad thematic areas that emerged from interviews
of key informants and focus group discussants. These
include: I) Understanding of Integration 2) Benefits of
Integration 3) Disadvantages of Integration 4) Barriers
5) Overcoming Barriers to Integration 6) Facilitators
for Integration 7) Potential Pathways to Integration 8)
Models of Integration and 9) Implications of Integration
should function as focal points of integrative activities
for UHC.
The term integration had multiple interpretations and
was used ambiguously and interchangeably with words
like 'coordination', 'collaboration', 'convergence',
‘cooperation’ and 'merger'. Several respondents
included other health determinants in defining
integration and equated the notion of integration with
inter-sectoral convergence or inter-departmental
coordination. When viewed In relation to disease
control programmes, integration was regarded as a
'process' that involved programmes working together
across different components of a health system (human
resources, financing, monitoring and evaluation etc.) for
optimum utilization of limited resources.
Integration at the service delivery level was
conceptualized as a function of multiple stakeholders
that included NGO’s, CBOs and the larger community
at which programme interventions are targeted. A
between a programme and its target population. Many
respondents felt vertical programmes should eventually
be integrated through a common stream of health staff at
the Primary and Community Health Centre levels [PHC
medical officer, ANM, Multipurpose workers, ASHA].
Respondents also viewed ASHAs, as the epitome of
integrated service delivery at the field level. It is also
interesting to note, that respondents also suggested
incorporating private practitioners as well as semi
qualified healthcare workers in this model of integrated
service delivery. Many viewed integration as the strategy
to place common managers to implement multiple
programmes at the district level with decentralisation
of health system governance at the district and lower
levels.
Most respondents stated that integrated delivery of
services was beneficial since it would allow greater
and more efficient utilization of resources through
pooled funding and shared manpower, logistics and
infrastructure
across
programmes.
Integration
of
certain programme components like accounting, data-
management, recruitment and procurement was also
seen as a major cost cutting strategy. Respondents
uniformly acknowledged that an integrated service
delivery system would bring about improved health
Identifying Operational Pathways for Integrating National Disease Control Programmes within
The Framework of Universal Health Coverage
outcomes through easier access, improved quality and
more affordable care.
The disadvantages of programme ‘integration’ were
also highlighted in the study as concerns around loss of
programme focus. In their current setting, each disease
control programme has its own focus and priority areas
targeting specific health interventions. However, when
components of such vertical programmes are integrated,
the dissolution of programme boundaries could
potentially dilute programme focus impacting efficiency
and effectiveness. A well conceptualized implementation
plan is therefore necessary in the integration of vertical
programme components to bring greater clarity to
programme roles and responsibilities. Power struggles
are also anticipated when programmes integrate,
especially at higher levels of programme management
where programme directors, senior bureaucrats and
political representatives could feel threatened at the
prospect of overlapping programme boundaries. This
bureaucratic
administrative
structures
and
poor coordination mechanisms posed challenges to
the easy integration of programmes. According to
many respondents administrative set-ups fostered a
culture of hierarchy where designations and contractual
conditions influenced the behaviour of programme staff.
Bureaucratic lethargy was manifested in many aspects
of program functions making staff in secure positions
in different to programme efficiency and effectiveness
and complacent about promotions regardless of
performance. Consequently, the inputs and opinions
of long-time staff with practical knowledge of the
field were often overlooked while recently appointed
administrators were given priority.
The need to address issues related to HR in terms
of their allocation, scarcity, remuneration and
rationalization were stark features highlighted. The
heterogeneity and rigidity in HR norms and policy
among the national programmes and the state health
could result in turf battles where programmes become
system was a major barrier foreseen by respondents.
protective in sharing of information, human resources
With different systems of recruitment, differential
and pooled funds.
The horizontal integration of programmes across the
Centre and the State could also pose challenges, as
every State has variations in their respective health
infrastructure and institutional capacities along with
diverse levels of engagement with the private sector
and other stakeholders. Challenges were also identified
around human resource (HR) development, their
retention and coordination. Pooling work forces
of different competencies, training, salary and job
descriptions would require both team coordination and
'learning of new skills’ to which existing staff may be
resistant.
Barriers to programme integration were identified in
Centre-State dichotomies where ‘separate guidelines’,
for each programme were issued at the Central level
with little consideration for State requirements and
autonomy. The historical positioning of programmes
into silos with each having separate mechanisms was
also identified as a barrier by respondents. This caused
programmes to focus only on their own priority areas
remuneration and predominantly contractual staffing,
the nationally funded disease control programmes may
find it difficult to accommodate its staff into the rigid,
tenure-safe and less incentivised general health systems
at the state level. The inability of the programme
managers and implementers in the speciality oriented
medical community to view health in its totality and
in in relation to the population was also recognized
as an important barrier in maintaining verticality and
preventing integration among programmes.
Programme funding occurring through several channels
was also seen as an obstacle to integration, as this
created multiple power and administrative control
centres. Funding driven verticalisation stemmed from
the fear that resources will be diluted and misused
for other health priorities, mistrust of the capacity of
state health systems and also from the control that a
funder wants to exert on their limited resources. As
an example, in the north-eastern states it is the central
funding of health programmes that dominates and
maintains programme verticality.
with little interaction with other programmes leading to
Potential pathways to integration defined along the
both inter and intra-sectoral isolation. The trust deficit
lines of strategies, processes and enabling environments
between public sector programmes and the private
necessitates
sector with each domain having vested interests was
among policy makers and administrators. Identifying
‘integratable’ programme components for successful
also seen as an obstacle to integration.
12
Highly
strong
leadership
and
enterprise
EXECUTIVE SUMMARY
respondents
felt
that
all
Control
integration as well as incorporating inter-sectoral
Many
integration was
considered imperative. Reforming the health sector by
strengthening monitoring and evaluation mechanisms
and proactive data sharing among programmes were
other suggested measures. Collaborating with different
stakeholders including traditional medicine providers
like AYUSH was recommended so as to create
an enabling environment and a shared ideology in
making programmes function in an integrated manner.
Empowering implementers and giving them a sense of
ownership of programmes would also prove as enablers
in moving towards integration.
Programmes should be eventually integrated with the
National Health Mission, which in turn will facilitate
integration and alignment with State health systems.
convergence
in
moving towards
Disease
In an example given on the integration of adolescent
health at the Primary Health Centre (PHC) level, it was
observed that no accountability was taken by both the
PHC and Adolescent Health Programme cadres for
integration activities as each felt it was the responsibility
of the other. Integration at the systems level therefore
needs to be strategically planned to prepare programme
staff for their new roles and additional responsibilities
Concerns were raised by participants about expanding
people to revisit this facility, resulting in considerable
savings on out-of-pocket expenditures for primary
health services. The Guwahati Medical College was able
to achieve this through performance evaluations with
service and quality control as an important indicator
and a motivated staff that believed in the brand and
the implementation of an UHC framework without
adequate consideration paid to the capacity of the
existing health system to absorb the integration of
multiple programmes along with adequate allocation
of funds to sustain this effort. Programme integration
will require rapid infrastructure expansion to keep
pace with increased coverage. Also, in the absence
of an essential health package recommended under
a UHC framework, the health system is likely to be
overwhelmed by an increased demand for diverse
health services. Respondents felt that a list of services
included as part of an essential health package (and that
could be provided through national health programmes)
should be affordable to state health systems who
will ultimately be responsible for delivering them.
reputation of the institution.
Respondents cautioned that the roll-out of UHC in
Quality control was identified an important component
in achieving inter-sectoral integration. A suggestion that
emerged in enabling better integrated programmes
was to use quality control and assurance parameters
in developing a brand for public sector services. A key
informant from Assam gave the example of Guwahati
Medical College, which consistently retained patients
who could afford to patronize private hospitals.
Maintaining a consistent quality of services motivated
Potential models of programme integration emerged
across three broad categories, namely: I) programmatic
level i.e. (integration of programmes at that involved joint
policy making, planning, and funding) 2) at the systems
level i.e. (where individual organizational components
are integrated between and among programmes, such
as M & E, HMIS, IEC, Operations etc.) and the at the
3) inter-sectoral level between the health systems and
India will have to be phased to prevent health system
overload exemplified by high expenditures, poor quality
health services and inadequate health outcomes. Finally,
the integration of traditional systems of medicine
(AYUSH) as part of a larger UHC framework and with
national programmes was also identified as a potential
challenge.
The Quantitative Study section utilized a 10-question
other sectors such as environment, water, sanitation
and nutrition. While programmatic integration (across
and within programmes) included integration of
financial, administrative, human resource areas as well
as service delivery at the field level, health systems
structured questionnaire which was scored using a
5-point Likert scale. The items were coded so that
a higher mean score on the instrument reflected
greater
frequency
of
programme
linkages.
The
questionnaire quantified attitudes across all national
integration involved the ability of vertical programmes
health programmes (disease control and promotive
to align themselves with the broader mandate of the
programmes) irrespective of their integration with the
National Health Mission (NHM), which could be one
NHM, focussing on eight programme components:
platform of delivery for Universal Health Coverage in
the country.
operations; 3) Activity-driven fund sharing and Infra
I) Policy level linkages; 2) Management and joint
13
Identifying Operational Pathways for Integrating National Disease Control Programmes within
The Framework of Universal Health Coverage
structure sharing; 4) Drug supply and Logistics sharing;
National Rural Health Mission (now National Health
5) Information, Education and Communication sharing;
Mission) that ranged from ‘Sometimes’ to 'Rarely'.
6)
Shared Data Management Information Systems;
7)
Common Monitoring& Evaluation system; and
Integrated Service Delivery. The tool helped to
8)
identify potential barriers to integration and elucidate
a potential role for a National Health Regulatory and
Development Authority (NHRDA) in the integrative
process (objective 4).
The frequency and level of integration of various
programme components between and across the IS
national health programmes is presented in a mosaic
plot in Figure 4. The plot illustrates the percentage
of responses to the ten questions on the Likert
questionnaire by all 128 respondents where the size
of each square corresponds to the percentage of
The graph shows that within current programme
contexts,integrative activities at levels of joint policymaking and establishing of programme guidelines
was seen to occur some of the time. Following this,
integration among programmes related to operations
and management activities that involved strategic
planning, formation of
Program Implementation
Plans
(PIPs) and capacity-building activities like
M & E, happened with much lesser frequency or rarely.
Interestingly, the frequency of joint programming
activities (where programmes shared common drug
procurement and logistics systems) was observed as
occurring ‘all-the-time’ and 'most-of-the-time' indicating
the role of NHM in bringing these component together
at the state level. Finally, integration activities around
shared infrastructure and human resources related to
the service delivery component of programmes was
also observed to happen with relative frequency among
programmes.
responses obtained for each question. The overall
weighted responses in the plot depicts the frequency
of integration of programme components that occurred
between or among programmes and/or with the
Figure 4: Mosaic Plot depicting frequency of responses to a questionnaire relating
to integration of programme components (n= 128)
Key
QI: Programs communicate during policy making; Q2. Programs develop joint guidelines with other programs; Q3. Programs
communicate during planning and formation of PIPs; Q4. Programs engage in joint capacity building activities; Q5. Programs
collaborate on monitoring and evaluation activities; Q6. Program funds are shared for common intervention activities; Q7.
Programs share a common drug procurement and logistic system; Q8. Information Education Communication (IEC) activities
are shared among programs; Q9. Programs actively share Management Information Systems (MIS) data; QIO. Programs
currently share infrastructure and human resources at the service delivery level.
Cooperation: QI & Q2; Collaboration: Q3, Q4, Q5; Joint Funding: Q6; Joint Programming: Q7, Q8, Q9, QIO
14
EXECUTIVE SUMMARY
Conclusion
& Recommendations
Review of integrated programmes shows that their
effectiveness, and the factors that facilitate or impede
success, depend substantially on the context in which
the intervention takes place.13 Attempts to integrate
programmes cannot therefore be seen as separate
from their service delivery, geographic, financial and
policy contexts. Although the autonomy of individual
jurisdictions have been sacrosanct in public health,
extendingthis principle to the design and implementation
of the country’s disease control programmes has
created challenges in conceiving a workable national
health system. On the ground, a programme’s context,
the organizational capability of a health system and
political clout of policy makers eventually influences
the extent of horizontal and vertical integration within
and between programmes and ultimately determines
solutions for efficient programme design. Both vertical
and horizontal approaches to program integration can be
beneficial in different contexts and can coexist in health
systems. In the long term, the limited evidence base,
highly varied contexts and differences in health system
capacity call for a pragmatic approach to programme
integration rather than reactionary approaches driven
by vested interests.
Political leadership along with the support of high-level
bureaucracy were considered essential facilitators
in catalysing programme integration at the policy
and programme design level. This was evident when
multiple programme staff repeatedly emphasized that
the health secretaries at the central and state levels,
along with the mission directors of the NRHM played
an important role in bringing about integration across
programmes at administrative, organizational and
service delivery levels.
In their present state the national vertical programmes
follow a bi-poiar model; where some programmes
work through State health departments and others
experience and evidence demonstrate that this method
of planning or programme design does not work in
the long term. Programme integration would result in
using alternative design elements through joint planning
and capacity building before they are eventually rolled
out at the national and state level. The one-size-fits-all
norms and design of many national programmes impose
inefficient restrictions on States and annual State plans
for programmes are made in a routine manner, without
consideration for the widely varying requirements
of the states. The result is a lack of state ownership
and routine efforts at implementation. When state
governments have the resources and freedom to
address their development problems, they are more
likely to generate accountability and effectiveness, often
missing from the current paradigm
There is tremendous support at the Central and State
levels for delivery of health services to all citizens
under the umbrella of UHC. Respondents felt that
that integrated national programmes could effectively
contribute to a much needed care continuum for a
UHC frame work that entailed cashless provision of
four critical services: free generic medicines, diagnostic
tests, provision for free transport to health facilities,
and basic nutrition for mother and child. Services
would be targeted at the entire population and not
just for those below the poverty line (BPL). Some of
the wealthier states were able to supplement their
NRHM funding allocations with additional budgets for
improving programme scope and activities. Integrated
programmes could serve as an ideal platform for such
holistic delivery of services to communities. However,
integration is also a managerial art and each programme
has varied needs for training and capacity-building for
managing and implementing integration’. Caution needs
to be exercised about the rapid expansion of UHC
without adequate consideration for health system
capacity and sufficient allocation of funds to sustain the
effort.
work through State managed societies. Both
arrangements tend to create multiplicity, fragmentation,
and administrative inefficiencies. Programmes were
Though
created with top-down designs where the Centre
professional affiliations had different interpretations of
provides funds and the States implement them. Both
the term ‘integration’, overall, the perceived benefits
programme
stakeholders
from
different
13 Powell Davies G, Williams AM. Larsen K. Perkins D, Roland M, Harris M. Coordinating primary health care: an analysis of the outcomes of
a systematic review. Medical Journal of Australia 2008; 188(S8) :S65-8.
H 15
I
Identifying Operational Pathways for Integrating National Disease Control Programmes within
The Framework of Universal Health Coverage
of integrating programmes at Central and State levels
to form coordinated networks that contributed to
better quality of care for individual patients, improved
population health outcomes and reduced costs was
Some disadvantages that
could result out of integration of programmes, such as
loss of programme focus, conflict between HR needs of
unanimously recognized.
different programmes were highlighted by participants.
State wide differentials also emerged in the quantitative
analysis with individual weightage given to specific
categories. Overall across all States and the Centre
the weighted ranks revealed that integration activities
in programme components related to 'cooperation',
‘joint programming’ and 'collaboration' were low. This
demonstrated that programmes still operated vertically
at State level revealing gaps in program efficiency
around policy planning, program design,operations,
human resources and drug procurement.
The role of State governments is central to success in
improving the capability and capacity of the Indian health
system and could put faith back in publicly delivered
services.
Deep disengagement of those entrusted
with the responsibility of delivering these services,
not only in their role as providers but also as users,
has depleted any incentive to improve performance.
However, restoration of state capability is not easy,
given its close interaction with political and civil society
dynamics, the politicization of bureaucratic processes,
administrative indiscipline, and erosion of accountability
in the discharge of official responsibilities and weakened
supervision and monitoring. Many progressive States
have aggressively pushed health reforms, invested in
health infrastructure, and courted private investment in
State run enterprise models.
Effective integration of national health programmes are
envisaged through both existing and evolving platforms
like: (I) the recently conceived National Health
Mission (NHM) that comprises of the rural and urban
health components. The NHM aims to improve health
outcomes by targeting phased increase in government
funding up to 2-3% of the GDP in coming years, by
addressing key health indicators; and (2) the National
Health Regulatory & Development Authority
(NHRDA) proposed in the High Level Expert Group
on Universal health Coverage Report 3 designed as
an independent national body linked to the Ministry
of Health and Family Welfare (MoHFW). The main
functions of the NHRDA will be to regulate and monitor
public and private health service agencies with powers
of enforcement and redressal. This regulator which will
oversee contracts, accredit health service providers,
develop standards for care delivery and quality
control and enforce patients’ charter of rights was
also identified as an appropriate platform to legislate
for the integration of preventive, disease control and
promotive programmes at all levels of healthcare.
Study Team
Principal Investigators: Dr. Priya Balasubramaniam, Prof. Subhash Hira, Prof. K Srinath Reddy
Research Team: Ms. Binira Kansakar, Dr. Preetha Menon, Dr. Aruna Bhattacharya, Ms. Aditi Singh
Dr. Souvik Bandyopadhyay
NORWEGIAN EMBASSY
This study was conducted with the generous support of the
Royal Norwegian Embassy (RNE)
16
PUBLIC
HEALTH
FOUNDATION
OF INDIA
For queries please contact:
Ms. Binira Kansakar (binira.kansakar@phEi.org)
www.m ehralm pressions.com
Public Health Foundation of India (PHFI)
Institute for Studies in Industrial Development (1SID) Campus
4, Institutional Area, Vasant Kunj, New Delhi-110070
Phone No.: 011-49566000, Fax No.: 011-49566063
www.phfi.org
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