This edition of HATIP looks at the question of integration between HIV services and other types of service within the health system. Integration has become a buzz-word in the HIV field over the past few years, but what do we mean by integration, who does it benefit, and where should the integration take place?

“Integration has become a very important word lately,” said Professor Wafaa El-Sadr, Director of the International Center for AIDS Care and Treatment Program (ICAP) at Columbia University. “[But we need] to think very carefully about what do we mean by integration; and at what level are we seeking integration? Clearly from the patient’s perspective, at the point of service delivery or the receipt of services – integration makes sense in terms of getting what they need in one spot and also from one provider. I think on the other hand it might behove us to think carefully about also: What are we integrating what into?“

Prof. El-Sadr was speaking at IAS 2011 in Rome as a panellist during a symposium that looked at the impact of the economic crisis on the HIV response, described the evolving relationship between HIV programmes and the general health system — and asked whether ‘integration’ (and decentralisation) could help sustain and increase the impact of HIV programmes.

But as Prof. El-Sadr suggested, it is important to first define exactly what is meant by integration, because it is a rather nebulous term that people use to mean different things. For instance, in the literature, the term integrated care often refers to the organisation of a variety of service providers, laboratories and pharmacies based upon for economic benefits (such as managed care organisations in the United States), or it may refer to the integration of service delivery.¹

In the HIV field, however, talk of integration can sometimes set off alarm bells among AIDS activists and HIV programme people. This is because ‘integrated care’ is sometimes a synonym for horizontal programmes (general health services) as opposed to vertical programmes (such as the national TB programme, the HIV programme, etc). In the damaging debates about whether the AIDS response has received ‘too much funding and attention’ at the expense of weak general health systems, vertical programmes were portrayed as being almost ‘parallel health systems’ that are inherently inefficient and which warp health system priorities.

Some parallel health system components, such as procurement and data management were sometimes established, particularly if the corresponding system in the general health service wasn’t up to the demands being placed on the HIV programme to demonstrate rapid results.

But, “In practice the dichotomy between vertical and horizontal is not rigid and the extent of verticality or integration varies between programmes,” Atun et al. wrote last year in a paper on integrating targeted interventions into health systems.²

The authors found that integration occurs over multiple levels in the health system and in relation to different health system functions. There are very good reasons why some functions for one programme were separate, and why some targeted (as opposed to general) service platforms may be needed. 

At the same time, there may be opportunities for integration created when there are demonstrable synergies and benefits between the HIV and other programmes (and these may evolve over time). For instance, integration at the service delivery level may provide more convenient services for the patient, or may produce some other benefit, such as expanding the reach and uptake of a service — or, quite simply, saving money by using the same infrastructure or resources for more than one purpose.

Service delivery integration can happen to varying degrees:

• Integrating an activity from one service into other service, such as providing intensified TB case finding or screening for sexually transmitted infected infections at an HIV counselling and testing unit; or
• Integrating most or all of one programme’s core services into another programme’s service delivery platform while both manage the same patient, such as introducing HIV screening, and care including ART for co-infected patients at TB clinics, or offering methadone-assisted therapy and other support services for people who use drugs into HIV or TB clinics, or providing screening and care for a co-infection or non-communicable disease (e.g, diabetes) at an HIV clinic.
• The process of integration also occurs whenever HIV services are being decentralised into general or primary healthcare facilities — which will then be offering more ‘comprehensive care’ — but an upcoming issue of HATIP will review some of the recent conference reports and findings on the benefits and dangers inherent in decentralisation.

When separate programmes integrate the delivery of services, other key health service functions — governance, financing, planning, procurement, monitoring and evaluation, and demand generation — may be involved, and may require joint co-ordination or sometimes, full integration. In certain cases, when the client overlap is particularly substantial, it has been suggested (and hotly debated) that entire programmes should perhaps become integrated from top down. A case in point is whether HIV and TB integration, which is increasingly being held up as the model for service integration, should go further in countries where there is a significant burden of co-infection.

“For example, up to 80% of the TB patients in Swaziland are also living with HIV. In Swaziland, there is an HIV programme, as well as a TB programme at the national level, which goes into the different levels of administrative levels.

"So is it really worth having separate programmes, or would it be better [more efficient] to merge the two programmes?” asked another panellist at the symposium, Dr Haileyesus Getahun of the World Health Organization’s STOP TB department. “But having said that I think it has to be really well thought out – the debate has to start – and evidence has to be generated. And with the increasing threat of multidrug-resistant TB, we’d also have to be very careful that the priority to manage MDR-TB doesn’t shift.”

Since programmes and priorities evolve, it may be important, from time to time, for health systems and HIV programmes to revisit whether there might be synergies gained from more integration — particularly when new tools become available or when the funding environment has changed.

There is a pressing need to look for such synergies because the current economic crisis (and the change in political will) has clearly threatened sustainability of donor funding and support for HIV programmes.

Speakers and panellists at conference symposia on integration explored whether there might be new opportunities created by the push to strengthen health system and programmes, particularly to reach Millennium Development Goals for health (MDGs).

Robert Greener, a senior economics advisor at UNAIDS, started the discussion by giving projections on the resource gap for the AIDS response and how the economic crisis and outlook might affect it.

“The financing situation is different in different countries, depending on the income level and the disease burden of AIDS,” he said (see table). Most HIV is in low-income countries, though some of the high middle-income countries have a high burden of HIV as well. Generally, however, it was the higher prevalence countries that were most affected by the economic downturn.

Countries with high or low HIV burden of HIV in relation with income

Greener presented new estimates from the UNAIDS Investment Framework, showing that global resource needs are set to rise from about $16bn in 2010 to $22bn in 2015, and should fall thereafter. About half of the need will be in the low-income countries, while almost one third of the need will be in the upper-middle income countries because of higher unit costs.

Meeting these needs will require an increased commitment from the governments of low- and middle-income countries as well as from international donors. Rather optimistically, Greener said that the economies of the low- and middle-income countries are expected to resume strong growth this year — and that this should increase government revenues that can be invested in the HIV response.

“However, a greater increase can be obtained from an improved allocation to health in general and HIV in particular,” he said. This is because the total investment in the HIV response tends to be much greater than the sums spent by poorer countries on their health systems, and so has been almost entirely donor dependent. Domestically, the level of HIV investment as a proportion of domestic health investment is consistently less than the HIV disease burden as a proportion of the total health burden.

“HIV does not get a fair share in national budgets,” Greener said.

In the best-case scenario — if countries abided by the Abuja Declaration and contributed at least 15% of the government’s revenue to the health budget, and if the domestic allocation for the HIV response is in line with the disease burden, the domestic public allocations could potentially double by 2017 and continue to increase thereafter. This would have the most impact in the middle-income countries and the need for external resources should decline in those countries.

The most rapid growth in domestic financing could be in low-income countries, but it won’t come close to meeting their total resource need and they will continue to need substantial external assistance.

During the discussion session, Dr Getahun noted that there is also a $24bn resource gap needed to implement the Global Plan to Stop TB 2011 to 2015. Most of the funding for TB control programmes has come from domestic sources — partly because the interventions for TB were cheap — and not lifelong (lasting around six months). But this is changing with the roll out of new tools, such as the GeneXpert test for drug resistance, and the urgent need to contain the MDR-TB epidemic — which costs much more to diagnose, treat and manage.

Something else that needs to be considered is whether failure to allocate funds today could result in much greater healthcare expenses tomorrow — the current burden of disease cannot be the only consideration when allocating healthcare resources. MDR-TB is a case in point. In a growing number of settings, MDR-TB must receive more than its fair share — as reflected by burden of disease — in the national TB programme budget, for the very simple reason that failure to mount an adequately aggressive response today could result in MDR-TB (or worse, extensively drug resistant-TB) spreading out of control. This consideration holds for other infectious diseases such as HIV as well.

But the fact remains that HIV is not even getting its ‘fair share’ in national health allocations — and that most countries are not eager to increase health expenditures during an economic crisis.

“There is great pressure for governments, especially in Africa, to increase their funding for health in line with the Abuja Declaration of 2001,” said another speaker at the symposia, Dr Velephi Okello, who is the National Co-ordinator for the HIV Care and Treatment Programme in Swaziland. However, she noted that very few have made these commitments. In fact, in March of this year (ten years after the declaration), only two countries had met the 15% commitment: Rwanda and South Africa.³ Meanwhile, it was reported that seven African countries have actually reduced their national heath expenditures since 2001, while twelve others have neither recorded a rise nor decline in government revenues applied to health.

Other possible ways to meet the resource gap, Greener said, would be to utilise innovative financing mechanisms at the global and country level. Zimbabwe has implemented a 3% AIDS levy on salaries, while other countries have implemented or are considering taxes on tobacco and alcohol, sugary drinks and foods high in salt or trans-saturated fats, and national health insurance. Other innovations include forms of indirect taxation (e.g., on international airline tickets, mobile phone usage — this is being done in Gabon — and exchange rate transactions); front-loading mechanisms, (such as the international financing facility), advance market commitments, voluntary solidarity levies and philanthropic foundations. Greener suggested that expanding domestic philanthropy could have an important role in some countries.

Aside from getting more resources, there are a couple of other options to help close the expected resource gap. One, Greener said, “is to break the upward trajectory of costs through the more efficient utilisation of resources,” including simplifying treatment regimens and delivery. This may be achievable through decentralisation, and switching to new treatment paradigms (Treatment 2.0) that rely more heavily on less expensive community-delivered treatment and care services.

The remaining option is “to integrate HIV programmes with other areas of the health system,” he said.

The opportunities and benefits relating to integration may be greater now than in the recent past, when many — including some working in Ministries of Health — were arguing that the HIV response was having a negative impact on health systems. According to Dr Leonard Okello, there is a now growing appreciation of what HIV is bringing to the table, and the recognition that extending the reach of high-quality HIV care and ART may be dependent upon strengthening and increased integration with other health services  — particularly primary health care.

“The experience we’ve had in lower middle income countries is that there are areas of synergy between HIV programmes and health systems in each of what the WHO has described as the six building blocks of the health systems: in governance, health care financing, the health workforce, medical products and technologies, health information and the delivery of services,” she said. “HIV programmes and health systems share common goals, which include improving health outcomes by addressing issues of equity and ensuring that in accessing health services, the population is protected from catastrophic expenditure.”

HIV programmes have demonstrated a number of ways in which health systems in resource-limited settings could improve the delivery of services. Approaches that have worked for HIV programmes include:

• The decentralisation of services
• The chronic care model
• Integration of services
• Community involvement
• Patient-centred health care
• Quality improvement.

Although HIV programmes started out being more verticalised — with services provided at specialised facilities, delivered by doctors and specialised personnel — Dr Okello stressed the paradigm shift represented by the decentralisation of ART services, to bring services closer to people in remote areas at the primary healthcare level, delivered by nurses and other community cadres. Critically, the decentralisation of ART services has been a major impetus for a movement to renew, revitalise and re-engineer primary health care — and these efforts have a better chance of success by incorporating the lessons HIV programmes have learned in a number of other areas.

For instance, “The implementation of the HIV chronic care model has put the emphasis on long-term continuous patient care versus episodic acute care which has been the norm in most of our health facilities. Furthermore, this model of care has enabled different levels of integration of services for other co-morbidities that the patient presents with to the healthcare worker. Healthcare workers have now had enough practice in implementing chronic HIV care that a similar approach to the management of other chronic illnesses, such as non-communicable diseases (NCDs) is being tried in countries such as Ethiopia [see below],” she said.

Closer integration of HIV care with the care of NCDs should ultimately improve the care of those conditions when they occur in people living with HIV. At the same time, they could also give health systems additional incentive to work together with the HIV programme to introduce and support the platform for chronic care and strengthen the capacity to provide long-term care for both NCDs and HIV, particularly at the primary care level.

“The opportunities for us to use these platforms to expand into delivery of care for all diseases, is right in front of us as well,” said Dr Eric Goosby, United States Global AIDS Coordinator during the panel discussion at the symposia. “Those opportunities must be taken; we must take advantage of it — not at the expense of the disease that we are focused on — but to allow us to take care of the other diseases that are present in the patient populations we are already interfaced with.”

It may behove programmes to investigate what services the clients of the health facility want (though demand generation activities may be needed to better inform communities of the availability of health services they are likely to need). But again, HIV programmes have shown health systems how to increase treatment literacy and community engagement.

“HIV has also broken down the barriers between healthcare facilities and communities [which] are now empowered in prevention, treatment, care and support, so that they have become an important part of the healthcare system. HIV programmes have involved communities in the delivery of services in facilities and PLHIV have been provided with skills for self-management of their conditions and to support others in their community,” said Dr Okello.  One of the components of primary health care is the involvement and participation of the community — and the unparalleled engagement of the community, particularly people living with HIV, in the HIV response may be critical to the success of the efforts to renew primary health care.

The HIV response has also provided opportunities to demonstrate the use of the quality improvement process (Plan, Do, Study, Act) to empower healthcare workers to find their own solutions and use their own data to evaluate their effectiveness. Quality improvement has helped programmes achieve previously difficult-to-implement interventions and improve programme performance. Health systems are now starting to use the same process in other parts of the health system to improve indicators for other conditions.

The HIV response has also led to changes in government attitudes toward health in many resource-limited countries. HIV programmes have been called upon to account for their performance reaching targets — and this has led to increased awareness and pressure on governments and Ministries of Health to be held accountable for reaching the health-related MDG-goals, “as evidenced by the renewed commitment of governments at the recent 2010 NY High Level Summit on MDGs,” said Dr Okello, who added that it is hoped that governments show a similar level of commitment at the upcoming High Level Summit on Non-Communicable Diseases in September.

Although not mentioned by Dr Okello, it should also be noted that the HIV response was only able to achieve many of its targets by bringing down the costs of diagnosis, care and treatment. In part, this was done by using flexibilities in the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS), including compulsory licensing and parallel importation, to promote access to affordable medicines in resource-limited settings. The health response will remain lopsided, with inexpensive care for HIV and expensive care for everything else, unless governments in these countries become more aggressive in the application of the TRIPS flexibilities to access affordable essential medicines for other health indications — and resist efforts to get them to give away these intellectual property rights in exchange for free trade agreements with the United States and/or European Union.

In an environment where the health system is held accountable for improving outcomes, increasing the local government’s allocation for health is in the best interest of the entire health system, including the HIV programme. In this economic crisis, it can be to everyone’s benefit to work together on innovative funding mechanisms for health — such as good national health insurance plans. Also, now that health system strengthening has received more funding from outside funders since 2008 — there may be areas where HIV programmes and health systems can pool their resources to achieve some common goals.

Areas of clear synergy include increasing human resources for health — in some countries, HIV funding has been used to strengthen healthcare educational institutions and training, including the development of strategies to better retain and manage those human resources. At the same time, HIV education clearly needs to be made part of the standard health education curriculum.

Health systems and HIV programmes can also benefit from the development of better patient management information systems. These were often piloted by HIV programmes, but are now being explored for use in overall patient management within the medical system.

Finally, the HIV response has improved the laboratory infrastructure in some countries. But a more important development may be the recent shift to developing simpler diagnostics, including point-of-care (POC) technologies that can be implemented by non-specialised healthcare staff in more remote clinics (such as POC CD4 and glucometers) — and which may play a key role in improving the services at primary healthcare clinics.

“In many countries, this is beginning to change the understanding of the essential healthcare package at the primary healthcare facilities,” said Dr Okello. “In many countries, there is a revision of this, because the scope of services provided at the primary healthcare clinics has expanded in terms of screening and provision of treatment.”

If indeed, there is a growing recognition of the potential synergies on both sides of the health systems ‘versus’ HIV programmes debate, there may be more opportunities to increase programme efficiencies through strategic integration in different services and areas of the health response — without compromising quality of care for people living with HIV.

If any one person could be given more credit for building bridges between health systems and the HIV response, it would be Prof. El-Sadr. During the discussion session, she cited the “tremendous transformation that the investment in HIV” has made in lives and health systems — and the many unique innovations that had come from it — and asked the audience whether we can use what we’ve learned to accomplish more — not just for HIV indicators, but for health in general.

”At this moment in time in the history of the epidemic, we are at the crossroads. We have tremendous opportunities not just to think about these transformations but also think very deliberately about what we are going to do with what we’ve learned and how can we look forward to learn more and also to achieve more — not just in HIV — and we have a long way to go in terms of reaching our goals, in terms of prevention and management of HIV — but also in achieving global goals, of reaching the Millennium Development Goals, and now the NCD goals and so on.”

“We need to think very carefully of where there are synergies in terms of these investments,” she added, listing a few key areas:

• Prevention of parent-to-child transmission (PPTCT) and enhancement of antenatal care to reduce maternal mortality and infant and child mortality
• TB and HIV
• Sexual and reproductive health and HIV
• Looking/planning ahead: Applying HIV’s lessons to confront non-communicable diseases and improve maternal child health services.

“People have commented on the many tools and many resources that HIV has brought about. But we have an opportunity now to see how would those work — can these tools be adapted to confront NCDs? Can these tools be adapted to enhance maternal and child health? Peer Educators have been very important for the HIV programmes — can they work in achieving optimal outcomes for diabetics; can they achieve optimal outcomes for maternal health and so on,” said Prof. El-Sadr, who went on to suggest that there are “massive opportunities” to adapt innovations in the delivery of care from the HIV field to serve other objectives in the health system.

But specific areas most ripe for integration, or collaboration, will depend largely upon the country.

“One size does not fit all,” said Dr Okello, since synergies vary from country to country. “Each country has to identify the areas where health systems and HIV programmes can work together to improve health-related outcomes,” she said, “These should be incorporated into each country’s strategic frameworks to strengthen both health systems and the HIV response, and donors and development partners should adhere to the Paris Declaration principles of aligning aid to national priorities and systems.”

“This choice has an ethical component to it, and those who are best positioned to make those decisions are those who are in the country and in the country leadership,” said Dr Goosby. However, he stressed that by country leadership, he did not mean just the government, but also civil society.

“In civil society those who are using the services are in the best position to feed back to allocators/appropriators who are prioritising a large unmet need to make the correct decision [regarding resource allocation],” Dr Gooby said, adding that the success of the US government’s Global Health Initiative, will “require that feedback loop to be intact and empowerment of the community to keep the dialogue honest.”

An example of this was provided by the final panelist, Svetlana Moroz, of All-Ukrainian Network of People Living with HIV, who stressed the disconnect between what the government in her country claims it does and what it is in fact doing.

“Despite the fact that the Ukrainian government has declared the support of the UNAIDS programme on universal access, they have made no provision in the state budget to fund it,” she said. “At the moment just one quarter of those who are in need of ARV treatment in the Ukraine receive it. The government of Ukraine has used the economic crisis as an excuse for its lack of political will.”

Structural problems in the Ukraine also limit access to services, and civil society in Ukraine has specifically demanded the scale-up of integrated services for HIV, TB and substitution therapy services for people using drugs. However, according to Moroz, the government in Ukraine, as well as other governments in the region, continue to waste money on narcological services that “are consuming large amounts of money while violating patient’s human rights but have minimal impact for public health and people’s lives.” In contrast, “evidence-based, human rights-based, gender-sensitive integrated services not only save money but are a response to patients’ needs, in particular confidentiality; and make it possible to receive several services in one place. “

Similar pressure must be applied to governments in Africa to adequately fund their health systems and the HIV/AIDS and TB response.

“But our countries in turn, should demonstrate their commitment towards increasing funding, by first fulfilling, or aiming towards fulfilling the Abuja declaration using available in-country resources and opportunities that exist to boost the health budgets,” said Dr Okello, stressing that governments must be held accountable for improving health outcomes in their countries. “Despite the economic crisis, the population still expects us to continue to provide health as a basic human right. So we have to be innovative, think outside the box and ensure that future generations do not blame us for failing them,” she concluded.

A third speaker at the symposia, Dr Fred Oboko, a political scientist from the French Research Institute for Development, in Marseille, France reported on a study evaluating the effects of ART decentralisation in Cameroon (which will be discussed more fully in an upcoming HATIP on the risks and benefits of decentralisation).

The clear subtext of the presentation was that new strategies to extend the reach of HIV services — whether integration or decentralisation — need to be evaluated to be certain that quality of care is not compromised, that other programme goals, such as prevention, are ultimately achieved — and that the approach is cost effective.

A number of the discussion panellists picked up on this theme.

“Clearly integration is a very popular concept but it is not a panacea, and we have to be careful. There’s a train that’s moving towards integration. We have to very carefully think and plan ahead and develop the indicators also to measure the outcomes in order to see whether we are losing some benefits by integration or gaining some benefits from integration,” said Dr El-Sadr.

Dr Goosby emphasised, “that the operational research agenda be explicitly defined and strategic in each country situation. And I think that operational research will give us the means through which we can make those decisions in an informed way and not in a random way. Having the ability to stop infections; having the ability to identify and retain the patient in care for the duration of their life is a system of care that needs to be robust on day one, and robust, still, thirty years later”

However, as noted in the HIV and TB in Practice section in this edition, it has been challenging even to demonstrate the true extent of improvement in health outcomes from HIV and TB integration. As Dr Getahun pointed out, several recent systematic reviews had failed to find evidence of the benefits of integration in the peer-reviewed literature. One study found no evidence to support the integration of PMTCT into other health system areas, while another pointed out that HIV integration into sexual health and reproductive services was always productive. It should be noted though that these systematic reviews cannot possibly have access to all the operational findings that have been generated by rapidly scaled up programmes. In the last ten years of the HIV response, interventions have evolved quickly, and implementation experiences have been shared at conferences, and best practices adopted, long before publication in the peer-reviewed literature.

Nevertheless, while Cochrane Reviews may be running behind the field, it remains important to generate, and document, the evidence in support of integration, and to identify if there are key factors that may make a difference between the success or failure of integrated interventions.

“There is a huge research agenda that is wide open; there are hundreds of questions that are actually very important to answer today. Some of these questions fall under the terms of implementation science or operations research. But I think it will behove many people who are involved across the many disciplines, i.e. economists, health systems experts, clinician implementers and many others to sit together and really come across to bridge those divides and try to sync up a common research agenda that will advance not only the learning and the science and technology but can also advance the gains that we are all trying to make in terms of population health,” concluded Dr El-Sadr.