2. Integrated Health Service Delivery Networks - 2014 1 |1 | INTEGRATED HEALTH SERVICE DELIVERY NETWORKS (IHSDN) - NETWORKS OF PERSONS Carlos Ayala Cerna, MD, MPH Health Systems and Services Advisor PAHO/WHO Belize Ramón Figueroa, MD, MPH Director Planning Unit Ministry of Health Belize

3. Integrated Health Service Delivery Networks - 2014 2 |2 | Objectives Know basic concepts of networking Know the way in which the integrated networks function Know the key elements of generating IHSDNs

4. Integrated Health Service Delivery Networks - 2014 3 |3 | “Networks” are persons connected (A) Networks, spontaneous (VOLUNTARY) ways in which persons organize themselves The links between two or more persons generate the unity of the network As in every human relation, the links are generated, constructed, nurtured but also can be deteriorated or destroyed

5. Integrated Health Service Delivery Networks - 2014 4 |4 | Networks have a purpose (B) VISION

6. Integrated Health Service Delivery Networks - 2014 5 |5 | Links (C) Basis for the construction of any network ACKNOWLEDGE that there is another person (actor), either as an intermediary or as an opponent. This assumes to REALISE and ACCEPT KNOW what the other is doing; assumes and generates…… INTEREST COLLABORATE and provide help in a sporadic way; assumes and generates ……. RECIPROCITY COOPERATE, share activities, knowledge and resource; assumes and generates ……. SOLIDARITY ASSOCIATE, generates shared activities or projects; assumes and generates ……. TRUST

7. Integrated Health Service Delivery Networks - 2014 6 |6 | In real networks……. Quantity, quality of links and conflicts Collaborate Meeting Knowing Conflict Cooperate Mediation

8. Integrated Health Service Delivery Networks - 2014 7 |7 | Some tips in building networks…. Common objectives : establish at least one, identified and recognized by all members. This gives identity to the group Define the goal, the purpose of the joint efforts and the contribution of each person. The group has to be organized, so the tasks and responsibilities are clear to all. Explicit will, of each member, to be part of the common effort and the network. Highly motivated to learn and to “forget previous practices”

9. Integrated Health Service Delivery Networks - 2014 8 |8 | Why to change…? Pressure for Change on Health Services Changes in demand Changes in supply Broad social changes Demographics Epidemiology The public’s expectations Health Services Technology and knowledge Workforce Financial pressure Globalization Government reforms Adapted from Mc Kee, M.; Healy, J. 2002 Sectoral reforms

10. Integrated Health Service Delivery Networks - 2014 9 |9 | The current situation…. Malaria-VBD Maternal and Child Health HIV/AIDS MoH Fragmentation of Health Services Social Security Traditional Medicine Private- low complexity NGOs Primary Level Municipalities Secondary Level Universities Occupational hazards Private- high complexity Tertiary Level

11. Integrated Health Service Delivery Networks - 2014 10 | The logic….R-PHC

12. Integrated Health Service Delivery Networks - 2014 11 | Conceptual framework

13. Integrated Health Service Delivery Networks - 2014 12 | The model……

14. Integrated Health Service Delivery Networks - 2014 13 | Primary care as a hub of coordination with hospitals roles and services

15. Integrated Health Service Delivery Networks - 2014 14 | The integration……but WHO – Making Health Systems Work, Integrated Health Services What and Why, Technical Brief Nro 1, 2008

16. Integrated Health Service Delivery Networks - 2014 15 | Do not forget…. Without hospitals there are no IHSDNs If the current logic, “hospitalocentric”, persists and prevails there are no IHSDNs Without IHSDNs, the current situation of the hospitals will not be solved (over burdened).

17. Integrated Health Service Delivery Networks - 2014 16 | Essential attributes of IHSDNs (1/3)

18. Integrated Health Service Delivery Networks - 2014 17 | Essential attributes of IHSDNs (2/3)

19. Integrated Health Service Delivery Networks - 2014 18 | Essential attributes of IHSDNs (3/3)

20. Integrated Health Service Delivery Networks - 2014 19 | Advantages of the network People’s experience with the system: Facilitate timely access to services at the first level of care Improve access to other levels of care when required Prevent duplication/unnecessary repetition of history-taking diagnostic procedures, and bureaucracy Improve clinical effectiveness Improve shared decision-making processes between the provider and the patient Facilitate the implementation of self-care strategies and chronic disease monitoring System’s overall performance: Improve the accessibility of the system Reduce the fragmentation of care Improve overall system efficiency Prevent duplication of infrastructure and services Reduce production costs Respond more effectively to people’s needs and expectations

21. Integrated Health Service Delivery Networks - 2014 20 | To keep in mind Integration processes are difficult, complex and very long term. Require extensive systemic changes; specific interventions are insufficient. Require a commitment by health care workers, health service managers and policymakers. Integration of services does not mean that everything has to be integrated into a single modality; multiple modalities and degrees of integration can coexist within a single system.

22. Integrated Health Service Delivery Networks - 2014 21 | BarriersFacilitators 1. Institutional segmentation and weakness of the health system, including a weak steering role 2.Sectoral reforms of the eighties and nineties (privatization of health insurance; health service portfolios that are differentiated across different insurers; competition among providers for resources; proliferation of contracting mechanisms; lack of job security for health workers; and regressive cost recovery schemes) 3.High-power groups with competing interests (specialists and ultra specialists; insurers; drug industry, medical supply industry,etc.) 1. High-level political commitment and backing for the development of IHSDN 2.Availability of financial resources 3.Leadership of the health authority and service managers 4.Deconcentration and flexible local Management 5.Financial and non-financial incentives aligned with the development of IHSDN 6.Culture of collaboration and team work 7.Active participation of all interested parties Barriers & facilitators of IHSDNs (1/2)

23. Integrated Health Service Delivery Networks - 2014 22 | Barriers 4.External financing modalities that privilege vertical programs 5.Deficiencies in the information, monitoring and evaluation systems 6.Weaknesses in system management Barriers & facilitators of IHSDNs (2/2) Facilitators 8.Results-based management