Progress and challenges on integrated care around the world

Progress and challenges onintegrated care around the worldThe experiences of Europe,the Americas and theWestern Pacific regions

September 2013

Presentations made at the IHF 38th World Hospital CongressOslo, Norway, June 2013

September 2013

The authors alone are responsible for the views expressed in this article and they do not necessarily representthe views, decisions or policies of the institutions with which they are affiliated.

www.ihf-fih.org P a g e | 1

Progress and Challenges on Integrated Care Around the World

Contents

Foreword by the IHF 3Eric de Roodenbeke

Synopsis by the WHO 4Hernan Montenegro

Integrated Care in Europe: Challenges, Progress and 5the Future Agenda - A Personal ViewNick Goodwin

The challenge of ageing societies in Europe 5

Meeting the challenge 6

The future 8

Roadmap for the Development of a Framework for 9Action on Coordinated / Integrated Health ServicesDelivery in the WHO European RegionHans Kluge

Background 9

Experiences 10

Challenges 10

Response 11

Challenges to Integrated service delivery in the 12Western Pacific RegionSjoerd PostmaThe challenges of health sector development in the Western Pacific Region 12

Introduction of Universal Health Coverage 12

Addressing health service delivery barriers 13

Successful examples of integration of health services 13

In conclusion 14

The authors alone are responsible for the views expressed in this article and they do not necessarily



Inter-provider Clinical Paths and Integrated 15Care in JapanTsuyoshi Ogata

The challenge 15

Meeting the challenge 15

Building a Regional Agenda for Hospitals in 18Integrated Health Service Delivery NetworksReynaldo Holder

Publications, studies and surveys 19

Meetings with Healthcare Managers and other Experts 19

Efforts towards Integrated Health Services 21In The English-Speaking CaribbeanIrad Potter

Historical Context 21

Shared Services 22

Successful Shared Experiences 22

Towards the Future 22

Bibliography 23



Foreword by the IHFHF has developed a longstanding relationship with WHOsince the early age of both organizations and althoughthere have been many changes in persons and major

evolutions in both organizations, this relationship has remainedsolid. Its foundation is a common goal to participate in improvingpeople’s health. Because the IHF represents the largest nationalplayers in service delivery and therefore deals with their area ofconcern and interest, our focus is very specific. However, weshare the constant quest for better health for people and astrong concern in the importance of equity to access along withefficiency for service delivery without compromising quality orpatient safety.

In a very fast evolving world it may seem inappropriate to sit andreflect on the last 30 years. Since Alma Ata, IHF has beenengaged with WHO in the global discussion on the role ofhospitals in health systems. In a historical initial meeting inKarachi, organized with the support of Aga Khan, it was madeclear that Hospitals should not be put aside, but instead fullyintegrated into health systems in order to support public healthpriorities. Although the world has dramatically changed, thisimperative remains the same while many new challenges havealso arisen.

The session organized by WHO and hosted by IHF during theOslo World Hospital Congress was an opportunity to scrutinizethe challenges the world faces in moving toward betterintegration of health services. In a landscape where chronicconditions are the key drivers of population health status, thechallenge of integration of care is a major priority for all.Considering the complexity of the issues to address, integrationwill not be an easy task. For this reason it is necessary to havea clear vision and a solid road map to guide the internationalcommunity. We can all be thankful for the leadership taken byWHO both at the headquarter and regional levels, to takeforward this matter and develop frameworks to help thestakeholders reconsider their practices and evolve toward amodel better responding to health needs of populations and theevolution of the social and economical landscape.

This session can be considered as a stage setting exercise thatwill allow for the accelerated implementation of the coreprinciples developed by WHO and fully supported by IHF. Thespecific role of IHF will be to strengthen the exchange ofknowledge of its members and the broader community of healthcare providers and to increase its advocacy for service providersto be more active in innovation of service delivery. The majorchallenge of healthcare is the fragmentation of players and theperceptions of that their priorities are related to the very specificenvironmental conditions in which they operate. Due to thisfragmentation, it is very difficult to harness the many evolutionsthat take place and to disseminate the good practices that resultwhen they do take place.

Because we are still at an early stage of what will become astrong wave in coming years, it is the perfect moment toincrease the mobilization in sharing experiences and practicesin people centered health care. We hope that this paper will beconsidered as a call for all those who have embarked on thisjourney to contact IHF to share their experience and results sothat we can fully fulfill our mandate in advancing the health ofpopulations by a high level of efficient service providers and highquality of care for those in need.

IHF is grateful that WHO participated very actively in the OsloWorld Hospital congress, and we look forward to thecontinuation and increase of such productive exchangesfulfilling the mandate of both organizations. A special thank youis due to Hernan Montenegro, who has coordinated this work,and to all of the speakers who have made this session possible.We hope that this publication will allow a large number ofhealthcare decision makers to take advantage of their valuablecontributions.

Eric de RoodenbekeCEO International Hospital Federation

*We really thank Kelley Hussey, student at Johns Hopkins, for doing the last revision of this paper.

I



Synopsis by the WHOhe path to universal health coverage draws attention tovarious barriers in access to health services linked tosignificant shortages in resources, fragmentation of

health care and lack of people-centeredness. Many healthsystems from around the world are characterised by high levelsof fragmentation of their health care systems.

Fragmentation of care manifests itself in multiple ways at thedifferent levels of the health system. At the system level,fragmentation can reveal itself as lack of coordination across thedifferent levels and sites of care, duplication of infrastructure andservices, and provision of care at the least appropriate location,particularly at hospitals. From the perspective of users,fragmentation of care expresses itself in lack of access toservices, loss of continuity of care, and failure of services tomeet users’ needs, demands and expectations.

Fragmentation of care can lead to significant difficulties inaccessing services, poor quality of care, inefficient use ofresources and low user satisfaction with services. Moreover,population aging, the emergence of chronic diseases andcomorbidities, and the ever increasing expectations from thegeneral population demand more integrated responses on thepart of the health systems.

The achievement of national and international health goals,including the MDGs, will require greater but also more effectiveand efficient investments in health systems. In recent years, thetrend in some countries has been to introduce policies andinterventions that promote more coordination and integration ofcare as a way to improve access, efficiency and continuity of

care. Despite these recent efforts, addressing fragmentation ofcare remains a significant challenge for the majority of countriesfrom around the world.

In an effort to tackle the problem of fragmented care, the WHO,its member states, and other partners such as the IHF areworking together to learn from, develop and implement moreintegrated models of care. As part of these efforts, the WHOhosted together with the IHF a parallel session on “Progress andChallenges on Integrated Care around The World: TheExperiences of Europe, the Americas and the Western PacificRegions” at the 38th World Hospital Congress, held in Oslo,Norway, in June 2013.

The parallel session held in Oslo looked at the experiences,successes, challenges and lessons learnt in trying to implementmore integrated models of care in three WHO Regions. Itexplored both recent technical cooperation initiatives promotedby the WHO Regional Offices in Europe, the Americas and theWestern Pacific Regions, as well as specific developments inEurope, the English-Speaking Caribbean countries, and Japan.

The WHO looks forward to continued collaboration with the IHFon matters such as this, and encourages more partnerships ofthis kind with other important international players in order toadvance the agenda of universal health coverage with moreintegrated models of care.

Hernan MontenegroHealth Systems Adviser, WHO Geneva

T



Integrated Care in Europe: Challenges,Progress and the Future Agenda- A Personal View

Dr. NICK GOODWINCEO, INTERNATIONAL FOUNDATION FOR INTEGRATED CAREAND SENIOR ASSOCIATE, THE KING’S FUND, UK

The challenge of ageing societies inEurope

Over the past two decades an important demographic andepidemiological transition has taken place in Europe, which hasseen age-related and long-term chronic illness replacecommunicable disease as the biggest challenge that healthsystems must now address. Today, more than half of thegrowing numbers of people aged over 65 in Europe are livingwith more than three chronic conditions, with about one-fifthhaving five or more concurrent health problems. This shiftmeans that the economic burden of age-related chronic illnessnow represents between 75-80 per cent of health careexpenditure, a figure that is also expected to rise as Europeansociety ages.

This rising demand for care presents a significant problem sinceit comes at a time of economic uncertainty. Health and welfarebudgets across Europe are under pressure yet the cost burden

of age-related chronic illness will rise. The ability to find a wayto sustain or even improve health outcomes within limitedfinancial resources has become the greatest of challenges,specifically when set against the European Union’s goal toincrease by 2 the average number of years that people live ingood health by 2020.

Current health and care systems in Europe, however, appear tobe ill-equipped to meet the challenge as they have over manyyears developed systemic and institutional structures that focuson cure rather than care. As a result, most countries have begunthe search for structural or technological solutions that embracenew and more integrated care models that place the emphasison preventing ill health, supporting self-care, delivering carecloser to people’s homes, eliminating waste and duplication, andreducing the reliance on hospitals and long-term careinstitutions.

Key Messages

Important demographic and epidemiological transition has taken place in Europe which has seen age-related andlong-term chronic illness replace communicable disease as the biggest challenge that health systems must nowaddress.

Current health and care systems in Europe, however, appear to be ill-equipped to meet the challenge as theyhave over many years developed systemic and institutional structures that focus on cure rather than care.

There is enough evidence and examples of practical innovation from across Europe that demonstrate it ispossible to improve care experiences and outcomes for people without adding to costs; however, the process ofchange is very complex and there is no ‘single model’ that can be applied to all contexts.

In recent years, many national governments across Europe have accepted the narrative in favour of integratedcare and have introduced policies and strategies to support it, including: structural reform, economic incentives,and legislative change.

Solutions also require the ability to develop both a cultural and operational willingness for collaboration at aclinical and service level, patients and carers becoming ‘fully engaged’ as co-producers of their own care, and thework force embracing multi-professional working.



Of particular concern in this movement for change is the rapid riseof those with complex long-term care needs, which tend to bemore common among the rapidly growing older populations inNorthern and Western Europe.

The complexity of needs arising from multiple chronic conditionscombined with the physical, developmental and cognitivedisabilities associated with old age – need the development ofmore integrated delivery systems that bring together professionals

and skills from both the cure and care sectors.

There is evidence, too, that people living in the moredisadvantaged communities within Europe’s major cities aredeveloping complex long-term health problems (particularlymental health care problems) much earlier in life than waspreviously recognised. Developing systems of integrated care tomanage the burden of the chronic care patient must, then,recognise that the pathology of multi-morbidity starts in childhoodand is conditioned by the socio-economic determinants of ill-health such as lower incomes, poorer housing, reducededucational attainment, social isolation, and higher levels ofsmoking and alcohol consumption. Any integrated care strategythat seeks to co-ordinate care better around people’s needs mustalso combine with it a focus on primary prevention.

Meeting the challenge

The good news behind the challenges presented above is thatthere is enough evidence and examples of practical innovationfrom across Europe that demonstrate it is possible to improve careexperiences and outcomes for people without adding to costs.However, what is clear is that the process of change is verycomplex and that there is no ‘single model’ that can be applied indifferent contexts. Indeed, multiple strategies are needed, andthese need to be applied simultaneously:

Due to the complexity and context-specific nature of integratedcare, the transfer of innovation from one community or countryto another is problematic. Whilst the change managementprocess for integrated care is not well advanced, key lessonsfor successful adoption include:

• Focusing on changing behaviours and cultures –integrated care is as much sociological as technical• Having a common vision and narrative with shared aims is

necessary, and this takesstrong and respectedleadership plus the time andenergy to put in place;• Finances and governancemust be aligned to desiredoutcomes – removingdisincentives is often moreeffective than adding newincentives or freedoms ontoexisting systems;• Care delivery systems mustbe restructured (e.g. lesshospital, more primary care);• Integrated care requires acommitment to continuousquality improvement sincethere will always beunintended consequences,hence the importance ofmeasuring outcomes andinvesting in research;

• Policy makers can provide the platform to enable andencourage integrated care to happen, but they cannotsuccessfully mandate for change.

In recent years, many national governments across Europehave accepted the narrative in favour of integrated care andhave introduced policies or pledges to support it. These havefocused on three main strategies: structural reform, economicincentives (linked to outcomes), and legislative change.Recent examples include:

Specific agencies in France (ARS) designed to help unitehealth and social care provision and better support thedevelopment of integrated care pathways

Coordination Reform in Norway and Denmark Joint agencies and/or associations to link funding and

delivery of care across primary, community, hospital andsocial care in Sweden (e.g. Jönköping and Nortallje,Stockholm)

The National Collaborative for Integrated Care and Supportin England

Versorgungsstrukturgesetz (care structure law) in Germanyto support interdisciplinary and cross-sector models of care

Managed care organizations and bundled payments fordisease management in Netherlands



Health and social care integration in Northern Ireland andScotland

Vertically and horizontally integrated care organizations tosupport better chronic care in many parts of Spain linked tofunding reform ( e.g. Basque Country, Catalonia, Valencia)

Physician networks and HMOs in Switzerland

A key tendency of these approaches has been to centralise theadministration and funding for integrated care, and/or to createspecific pilot or demonstration projects, yet it can be seenthrough research that such approaches have not had asignificant impact in enabling change at the scale and pacerequired to meet future needs. This is because achievingintegrated care cannot be successful if it is only mandated fromabove since the levers for change are limited. Successfulstrategies need to be driven from the bottom-up, a process thatrequires significant effort and investment.

At a pan-European level, through the Health 2020 initiative (aEuropean policy framework supporting action acrossgovernment and society), the European Innovation Partnershipon Active and Healthy Ageing B3 Action Group on IntegrateCare has been established to share knowledge and promoteaction on integrated care adoption from committedorganisations and regions across the EU. Within this, there is

recognition that a focus on improving health has both a strongsocial and economic case, and that approaches to integratedcare need to more quickly demonstrate such impact.



The Future

Caring for the growing number of (older) people living withcomplex and long-term care needs will be the primary ‘business’of European health and care systems in the coming decade.Attempting to recalibrate the way care is provided to meet suchchallenges will take time, but the burning platform created by theeconomic crisis, combined with the changing demographics ofdisease has created a compelling case for change. The solutionrequires the ability to develop both a cultural and operationalwillingness for collaboration at a clinical and service level (with theinvestment to match to develop the necessary capacity andcapability). More needs to be done to engage patients and carersin becoming ‘fully engaged’ as co-producers of their own care, andthe work force needs to adapt to embrace multi-professionalworking.

Nick Goodwin is co-Founder and CEO of the InternationalFoundation for Integrated Care (IFIC), a not-for-profit membership-based foundation dedicated to improving the science knowledgeand application of integrate care across the World(www.integratedcarefoundation.org) and is Editor-in-Chief of itsscientific periodical the International Journal of Integrated Care(www.ijic.org). Nick also works as a Senior Associate at The King’sFund, London supporting its programme dedicated to improvingand integrating care to older people and those with long-termconditions (LTCs).

Nick’s portfolio of work includes UK, US and European-basedcase-study research examining the development and impact ofintegrated care to people with complex and long-term healthproblems. Nick continues to work with the UK government tosupport its policies on integrated care, including the evaluation ofits health and social care integration pioneer programme. Nicksupports international commitments to the application of integratedcare within the European Union as part of the research teamProject INTEGRATE (www.projectintegrate.eu), SMARTCARE,and the European Innovation Partnership on Active and HealthyAgeing. Nick is leading work for the World Health Organisation tosupport the development of a Global Strategy to develop person-centred and integrated care and it’s European ‘road map’ tosupport co-ordinated and integrated health service delivery.



Roadmap for the Development of aFramework for Action on Coordinated /Integrated Health Services Delivery in theWHO European Region

Dr. HANS KLUGEDIRECTOR, DIVISION OF HEALTH SYSTEMS AND PUBLIC HEALTHWORLD HEALTH ORGANIZATION, REGIONAL OFFICE FOR EUROPE

BackgroundIn the WHO European Region, present efforts are guided by thenew European health policy, Health 2020, committing MemberStates to achieve the Region’s health potential by year 20201.This umbrella policy framework places great importance onhealth system strengthening as one of its four priority areas.Central to improving the performance of health systems aretransformations in how services are delivered – thecoordination/integration of health services delivery being a keyapproach to ensuring these transformations are realized andthat people-centred health systems are secured.

A number of factors are found to drive the neededtransformations in services delivery across the Region. Thesefactors include the following:

1 WHO Regional Office for Europe. (2012). Health 2020 Policy Frameworkand Strategy. Regional Committee for Europe Sixty-second Session.Copenhagen: WHO Regional Office for Europe.2 Health for All Database, August 2012 update

shifting population demographics, as the population in theEuropean Region is living longer than ever before with the lifeexpectancy at birth among Member States averaging 76.6 yearsin 2011, while fertility rates continue to fall (averaging 1.64 in2011)2; a rise in non-communicable diseases (NCDs) andrelated multi- and co-morbidities, with NCDs accounting for thelargest proportion of mortality and premature death(approximately 87 percent of all deaths annually)3; thepersisting challenge to control the spread of emerging and re-emerging communicable diseases, including HIV-infection andtuberculosis; and the increasing expectations of citizens aseducation levels continue to rise and information becomes morereadily available4.

3 Pfizer. (2011). The global burden of noncommunicable diseases. USA:Pfizer Inc.4 Kickusch, I. & Gleicher, D. (2012). Governance for health in the 21st

century. Copenhagen, Denmark: WHO Regional Office for Europe.

Key Messages

Health 2020 calls for people-centred health systems, requiring countries from across the Region to adapt healthservices delivery to emerging changes including changing population demographics, increases in non-communicable diseases and multiple co-morbidities, a context of economic scarcity and the rising expectations ofcitizens for service quality and safety.

Transformations in the delivery of health services have widely emerged across the Region. While taking differentforms, these efforts ultimately share in their overarching aim to overcome the challenges of fragmentation in theprovision and financing of health care services towards gains in the quality and continuity of care.

Challenges to further implementing initiatives across the Region include responding to the following: neededleadership and managerial capacity to scale-up location and/or disease specific initiatives; overcoming persistinghealth system bottlenecks; and advocating for the coordination/integration of services in times of financial hardship.

In response to the current context and at the request of Member States for needed policy-options, the RegionalOffice has embarked on a long-term work plan to develop a Framework for Action towards theCoordination/Integration of Health Services Delivery (CIHSD) for presentation and endorsement of Member Statesat the 66th meeting of the WHO Regional Committee for Europe in 2016.

Progress



A misalignment between the challenges of today and the existingmodels of care, however, has subjected services to obstaclesincluding the overuse, underuse and misuse of services,uncoordinated arrangements in the delivery of care, a biastowards acute treatment and the neglect of preventative andsocial care services. Importantly, in the context of the globalfinancial crisis – felt to varying degrees across the Region – thechallenges of social protection, particularly for chronically ill-people and vulnerable populations have been exacerbated.Moreover, in this era of continuous advancements in medicaltechnology, there is added strain on already limited resources toimplement even modest investments.

ExperiencesAcross the Region, reforms in the delivery of care towards moreintegrated services have widely emerged in acknowledgement ofsustainability and quality concerns and the need for moreequitable, comprehensive, integrated and continuous responseson the part of the health system. While the specific ‘integratinginitiatives’ applied and their strategic combination are found to

vary by a given context and a system’s related pathdependencies, these efforts ultimately share in their aim toovercome the challenges of fragmentation in the provision andfinancing of health care services. Examples of these initiativescan be found across the Region, some of which have beensummarized in Table 1 below.

The experiences across the Region and related literature agreewith growing consensus on the potential for positive outcomesto be secured for the quality and continuity of care, towardsimproved health outcomes. For citizens, strengthening theintegration of services has been found to contribute to improvedaccess to appropriate services, individualized care, improvedconsistency in health personnel, and to strengthening patient-provider relationships.

Challenges1. Scaling-up location and/or disease specific initiatives.

Interventions towards the coordination/integration of healthservices delivery (CIHSD) are commonly driven by the local

Table 1 Examples of initiatives towards the coordination/integration of services in the RegionCOUNTRY AIMS DESCRIPTION OUTCOMES

Estonia5

To fully integratecommunication through anational electronic health

record system, linking acrosslevels and sites of care

National electronic health recordhosting over 3,000 e-services andcompanion health insurance systemfor claims, reimbursement andprescriptions

Implementation costs equivalent toapprox. $10 USD per citizen

Efficiency gains via the directcommunication between institutionsand providers

Engagement of individual receivingcare via personal health record,virtual medical center and mobilepatient applications

Germany6

To implement integrated carepathways for selected

treatments towards improvedrehabilitation of patients forthe return to work within a

shorter time period

Integrated contracting model forcoordination between casemanagers, doctors, psychiatrists &physiotherapists

Selected procedures (e.g. paintherapy); targeted population

Patients treated through integratednetworks found to return to work 72days earlier than those treatedthrough conventional care pathways

Hungary7To coordinate the delivery ofservices and collaboration of

providers in primary care

Capitated budget for participatinggroup practices to cover all primarycare services of a given population

Incentives for prevention servicesand retained savings of practices forreinvestment

Improved collaboration amongproviders

Decrease in inappropriate services Increased attention to preventive

services

Israel8

To provide an integratednetwork of hospitals, primary

and specialized clinics andpharmacies towards high

quality, people-centred care

Services adapted to uniquepopulation sub-groups

Prioritize innovative care modelstargeting continuity of data, caretransition, & strengthening hospital-community care linkages

Improvements in preventing hospitalreadmission

Strong continuity of care viaattention to patient preferences andhome and community supportsystems in place

5 For further information, see for example: Estonian eHealth Foundation (2013). Health information system. Retrieved from http://www.e-tervis.ee/index.php/en/health-information-systems.6 Initiative of Techniker Krankenkasse – Statutory Health Insurer. See for example: Wagner, C. (2012) Lessons from Germany: Implementing integrated care asa statutory health insurer. London: The King’s Fund.7 For further information, see for example: Evetovits (2011). Exploring new ways to pay health providers and improve performance. Barcelona: WHO BarcelonaOffice for Health Systems Strengthening.8 Balicer, R. (2013). Clalit health services. [powerpoint] for WHO Regional Office for Europe.

Progress



initiative of specific facilities or health care providers. Whileresponding to the unique needs of a given sub-group of thepopulation or geographic area, these changes are oftenincremental, lacking the needed leadership and managerialcapacity to bring efforts to scale.

2. Overcoming persisting health system bottlenecks.Incremental changes ultimately do not address persistinghealth system bottlenecks contributing to fragmentation andlack of coordination in the delivery of services. This includesfor example: the systems-thinking needed to implementinformation technology that enables the coordination ofcommunication across levels and sites of care; contractingmodels conducive to the collaboration among providers;and/or payment incentives that are complementary inmotivating integrated efforts.

3. Advocating the coordination/integration of services in times offinancial hardship. In the context of the current financial crisis,austerity measures are high and efficiency in the servicesdelivery is a priority for reform efforts. Inconsistent data onefficiency gains for the CIHSD, in addition to possible short-term investment costs, pose a significant challenge toadvocating the interventions needed for the integration ofservices. Ultimately, priority must be given to communicatingthe long-term gains in quality and continuity of care and theprecedence this must take in order achieve people-centredhealth systems.

Response

Building on a number of efforts at the Regional Office9, a long-term work plan for developing a Framework for Action towardsCIHSD has been defined. This work is envisioned as a platformto accelerate the efforts of Member States to plan, implement orscale-up initiatives towards more integrated care. The work planhas been defined along six phases towards the endorsement andcommitment of Member States to prioritize the CIHSD at the 66thmeeting of the WHO Regional Committee for Europe inSeptember, 2016.

The envisioned Framework for Action towards CIHSD is definedby three complementary components: (1) the synthesis ofknowledge, giving a narrative to key concepts and existingliterature on the coordination/integration of services; (2) fieldevidence cataloguing the first-hand experiences of countries indeveloping, implementing and scaling-up initiatives; and (3) thetranslation of knowledge and experiences into pragmatic andactionable policy options. Through these components and aparticipatory approach to their development, the Framework forAction towards CIHSD aims ultimately to generate the leadershipand managerial skills needed for change management, theevidence-base to advocate for CIHSD in times of resourceconstraints, the technical capacity in-country to implement efforts

9 This includes for example the following publications related to health servicesdelivery: the application of the Primary Care Evaluation Tool (PCET) across theRegion; Rechel et al. (2009) Investing in hospitals of the future. Copenhagen:WHO, on behalf of the European Observatory on Health Systems and Policies;

and a network of partnerships for the continued discussion andexchange of experiences for the integration of care.

Hans Kluge is a Belgian trained medical doctor with a Mastersdegree in public health. Previously based in the WHO CountryOffice in Myanmar and the WHO Director-General’s SpecialRepresentative Office in Russia, he has a wealth of country andmanagement experience spanning several WHO Regions with abackground in health systems, public health and infectiousdiseases, including Somalia, Liberia, Siberia (prisons), CentralAsia and Caucasus.

Dr Kluge moved to the WHO Regional Office in Copenhagen in2009 when he was recruited to the position of Unit Head, CountryPolicies and Systems and has since worked as the RegionalDirector’s Special Representative to Combat M/XDR-TB in theEuropean Region and most recently as Director, Division ofHealth Systems and Public Health.

Edwards (2011). Improving the hospital system in the Republic of Moldova.Copenhagen: WHO Regional Office for Europe; WHO Regional Office for Europe(2012). Modern health care delivery systems, care coordination and the role ofhospitals. Copenhagen: WHO Regional Office for Europe.Progress



Challenges to Integrated Service Deliveryin the Western Pacific Region

SJOERD POSTMATEAM LEADER, HEALTH SERVICES DEVELOPMENTWHO OFFICE FOR THE WESTERN PACIFIC REGION

The challenges of health sectordevelopment in The Western PacificRegion

The Western Pacific Region, home to nearly half of the world’spopulation, has possibly the largest diversity of any of the WHOregions with low-income countries like Lao, PNG and Cambodiaat the lower end of the spectrum and Japan and Australia at theother end. This is also reflected in their level of health sectordevelopment. While a number of countries are primarily focusingon providing services for the ‘traditional’ communicablediseases (occasionally fuelled by geological disasters ordisease outbreaks) through an extensive PHC network, othersare struggling providing long term care for the ‘new’ epidemic,i.e. Non-Communicable Diseases, particularly cancers, heartdiseases, diabetes and chronic pulmonary diseases; most ofthem at higher level care in hospital settings. In addition thereare perennial health systems problems, such as underfunding ofthe health sector, lack of sufficient human resources and, when

they are there, not having the appropriate skills or knowledge.Leadership and governance also prove invariably weak, leadingto, amongst others, an inefficient sector and uncontrolled growthof the hospital sector. Each one of them will in turn have asignificant influence on the level of (integrated) service deliveryleading to, amongst others, high out of pockets payments byindividuals, disjointed service delivery and different levels ofquality of care and eventually different success in terms ofMillennium Development Goals (MDGs) outcomes.

Introduction of Universal HealthCoverage

With 2015 just around the corner, the international communityhas identified Universal Health Coverage or UHC as one of thesocial (health) development goals in the post 2015 agenda.

UHC is about providing all people access to quality serviceswithout them falling into financial hardship getting thoseservices. While still a developing global concept, the WPRO

Key Messages

Health sector development reflects the diversity of the Western Pacific Region, with countries making significantdemographic and epidemiological transitions that impact service delivery in the region. Age-related and long-termchronic illnesses are replacing communicable diseases as the prime movers of the disease burden, often fuelledby regional outbreaks and ecological disasters.

In addition there are perennial health systems challenges, such as underfunding of the health sector, high out ofpockets payments by the population, insufficient quality human resources, weak leadership and governance, andan uncontrolled growth of an inefficient hospital sector.

Universal Health Coverage requires countries to have a much more focused and integrated health service deliveryapproach, that addresses health (services) needs following a person’s ‘life course’. It also requires that services areAccessible, Available, Affordable and Acceptable (four ‘As’) to or for the people. Taking the four ‘As” from both ademand and supply side perspective will provide an indication where possible barriers to service delivery exists thatmay need to be addressed.

Given the diverse background of the Western Pacific countries, their level of service integration will also be atvarious stages based on a different context, different pace of development or the different challenges faced bythem, countries will have different options to address their specific service delivery barriers.

Upcoming national health sector planning for the period 2015-2020 in most WPRO countries gives an opportunityto operationalize strategies to address service delivery barriers; barriers between services, between health andother sectors, between public and private services (including the NGO sector), and between services and specificdisease programmes.



countries have widely embraced the new direction that UHCprovides for countries’’ health sector development.

However being multi-dimensional it also poses difficulties howachieving UHC should be measured. Forexample, while China has almost 100 per centcoverage of health insurance for its people, thepublic health service delivery package is ratherlimited, so people will still go to the private sectorand thus pay a substantial amount out of pocket.

Secondly it may also be rather difficult totranslate the UHC concept into actual servicedelivery on the ground or inform the populationat large. All they want is service delivery; if thereis no service delivery people will ‘vote with theirfeet’ and seek for it elsewhere, often at a muchhigher cost.

Thirdly, UHC does not provide a prescription tointegrate services either. A continuum of careapproach addressing health service needsfollowing a person’s ‘life course’ should becomprehensively available in a place nearwhere the population lives at an affordable priceand of acceptable, often cultural sensitive,standards

Addressing health service deliverybarriers.

A useful approach countries are increasingly encouraged to useis to address integrated service delivery by ensuring thatservices should be Accessible, Available, Affordable andAcceptable ( four ‘As’) to or for the people. Reviewing those four‘As” from both a demand and supply side perspective willprovide an indication where possible barriers to service deliveryexists and may need to be addressed.

For example, immunization services may be provided on aweekly basis (supply side availability issue) but not at the weeklymarket day that would ensure that women bring the children intotown (demand side acceptability and accessibility issue).Another example: Family planning services may only provideoral contraceptives (availability supply side issues), while thereal demand from the women may be injectable contraceptivesas this provide them surety for a longer period and/or may hidethe fact that they are taking contraceptives from their partners(demand side acceptability and availability issues)

However, considering the wide range of health sectordevelopment in the Western Pacific countries, the level ofservice integration will also be at various stages based ondifferent context, different pace or the different challenges facedby countries.

Hence the proposal to provide a menu approach of servicedelivery issues and their barriers that different countries may optto choose from and /or prioritize the relevant issues. The textbox below provides an overview of such a possible menuapproach.

Successful examples of integration ofhealth services.

Successful examples of different levels of integration of servicesin the Western Pacific region are: The use of ambulances (Cambodia) or specially hired taxis

(Laos) to move patients to/from hospitals; The integration of traditional and allopathic health services

in district hospitals in Viet Nam;

Figure 1: Universal Health Coverage dimensions.

Figure 2: Improving and integrating service delivery.



The reduction of drug prices to at-cost levels in China,allowing clients to seek services in public health facilities asdrugs can be provided;

Health insurance penetration to all service delivery level inPhilippines, again allowing patients to seek services wherethey want;

Dual practice laws in a number of countries, allowingdoctors to have both public and private practices,sometimes even in the same institutions; and

Compilation of special programme incentives for all staff tobe shared in Cambodia.

In conclusion.

As no shoe fits all, countries will need to make choices basedon their own contexts. With new rounds of national healthsector planning for the period 2015-2020, starting from 2014 formost WPRO countries, it gives an opportunity to operationalizestrategies to address service delivery barriers; barriersbetween services, between health and other sectors, betweenpublic and private services (including the NGO sector), andbetween services and specific disease programmes. Providingsuccessful examples and technical facilitation by organizationslike the WHO, especially at country level, will be useful in theprocess.

Sjoerd Postma is a public health services managementspecialist with 25 years of experience in international healthsystems development as well as health sector development andreform with a particular emphasis on Primary Health Care,having worked at national, intermediate and operational levelsand in the public, private and NGO sectors. He has developedhealth sector programmes in Ethiopia, Uganda, India, Laos, andViet Nam.

His health services management experience includesexperience in planning and implementation of health systemsfor service delivery, budgeting and financing, healthinfrastructure development (hospitals, health centres, trainingschools, information technology/GIS and equipmentmaintenance units), contracting of consultant services,monitoring and evaluation.

His technical skills relate to mother and child health diseases,family planning, reproductive and sexual health, essential drugs,HMIS, TB, HIV/AIDS, leprosy, health worker education.

He has wide agency experience having worked for and/ordesigned/evaluated projects for USAID, Danida, DfID, DutchGovernment, World Bank, ADB, UNICEF, WHO and theLuxembourg Government, while working long-term in tendifferent countries in Africa and Asia.

Lastly he has taught in different public health servicemanagement, childhood and tropical disease subjects atuniversities and institutions in the Netherlands, the UK, Kenya,Uganda, South Africa, India, Indonesia, China and South Korea.



Inter-provider Clinical Paths andIntegrated Care in Japan

TSUYOSHI OGATA,MD., PHD, CHIKUSEI PUBLIC HEALTH CENTER,IBARAKI PREFECTURAL GOVERNMENT, JAPAN,DIRECTOR, JAPANESE ASSOCIATION OF PUBLIC HEALTH CENTER DIRECTORS

The challenge

Japan is facing a fast-growing demographic challenge. In 2012,24 percent of the total population was 65 years and over. In2050, the aged population will be 40%.The leading causes ofdeath in Japan are noncommunicable diseases such as cancer,heart disease and cerebrovascular diseases. It became achallenge to ensure a seamless provision and effectiveintegration of various care providers for these diseases inJapan.

Conceptually, patients with cerebrovascular attack(CVA) are hospitalized at acute health carehospitals at first, and they then transferred torecuperative rehabilitation hospitals, long-termcare facilities and home care in turn as theyrecover. Coordination and collaborations arerequired.

In Japan 80% of people die at institutions includinghospitals and only 12% of people die at home.However, a survey shows that 83 % of peopledesire to die at home. In order to satisfy this desire,further development of multidisciplinary integratedhome care is also essential.

Meeting the challenge

The Medical Care Act was amended in 2008 so that RegionalHealth Planning (RHP) is required accordingly to include

disease-oriented inter-provider clinical pathways for fourdiseases: cancer, acute myocardial infarction, diabetes,cerebrovascular attacks. The Regional Health Planning shouldalso specify health care facilities and their care services.

Key Messages

The leading causes of death in Japan are noncommunicable diseases such as cancer, heart disease andcerebrovascular diseases. Japan’s challenge is to ensure seamless provision and effective integration of variouscare providers for these diseases.

The Medical Care Act was amended in 2008 so that Regional Health Planning (RHP) included disease-orientedinter-provider clinical pathways for four diseases (cancer, acute myocardial infarction, diabetes, cerebrovascularattacks). The reform also introduced a regional inter-provider care planning fee for cerebrovascular attacks (CVA).For reimbursement, providers must be listed in the clinical pathways in each prefectural Regional Health Planning.

Information Communication Technology has also been used for home care, facilitating information sharing amongproviders and networking. The system includes a scheduling master function, a common index function (like vitalsigns, photos), and a team messaging function.

Clinical pathways have facilitated collaboration and mutual trust among facilities and providers, and ultimatelyimproved quality of care and patients outcomes. The Regional Health Planning and National Uniform Fee havepromoted the implementation of the clinical pathways.

Participation of Public Health Centers in disease-oriented care coordinationand introductions of clinical paths (out of 246 PHC responses, 2009)

Disease Cancer CVA AMI DM

Primary careCoordination

82(33%)

179(73%)

57(23%)

93(38%)

PathsIntroductions

30(12%)

117(48%)

30(12%)

42(17%)



According to the research in 2009 by Japanese Association ofPublic Health Center (PHC) Directors, 73% of primary careproviders participated in the coordination of care, such asholding network meetings or workshops, among local carefacilities for patients with CVA and 48% of primary careproviders were involved in introductions of disease-orientedclinical paths

In the 2008 health insurance fee schedule, a regional inter-provider care planning fee for CVAwas introduced. Forreimbursement, providers must belisted in the clinical pathways ineach prefectural Regional HealthPlanning.Regional inter-provider careplanning fee is charged at ¥9000 or$100 /discharge for acute healthcare hospitals. The average lengthof stay for hospital care should beunder 17 days for qualification tocharge the fee. The charge is$60/discharge for recuperativerehabilitation hospitals, and$30/discharge for long-term careproviders.

In Regional Health Planning ofIbaraki prefecture, 24 acute healthcare hospitals are listed for cerebrovascular attack; 16 out of 24hospitals actually charged the care planning fee. Twentyrecuperative rehabilitation hospitals out of 50 the listed hospitalsalso charged the fee.

In the southern part of Ibaraki prefecture, some of acute carehospitals and recuperative rehabilitation hospitals voluntarilyheld multi-disciplinary network meetings for prompting CVA carein 2008. Fourteen hospitals began to use a common report formfor sharing information of patients with CVA. It did not shortenthe length of stay (LoS) for the patients at hospitals because of

the absolute shortage of long term care facilities or home careservices. However, it improved daily activities ofcerebrovascular patients more; so it might have improved thequality of careInformation Communication Technology (ICT) is useful for homecare because the care is provided by various independentproviders. The Fujitsu Company has developed a “Home teamcare system” which consists of mobile devices and cloudservices. It has a scheduling master function, a common index

function (like vital signs, photos), and a team messagingfunction. The system is useful for sharing information amongproviders and it supports multidisciplinary human network.

Our public health center holds multidisciplinary meetings forpromoting home care in the community. The meetingparticipants are clinic physicians, home visiting nurses, homehelpers, pharmacists and other care providers in the area.Through our experiences, personal networking and mutual trustare the most important. Clinical paths facilitate collaborationsand mutual trust among facilities and providers and then

ultimately improve quality of care andpatients outcomes. Regional HealthPlanning and National Uniform Fee havepromoted implementations of the clinicalpaths. ICT solution may also be aneffective tool to supplement the humannetwork but cannot replace it.

Further Improvement of Barthel Index (BI) for CVA Patients at discharge from Recuperativehospital comparing to BI at discharge from Acute hospital After application of the Pathwaywith the form. BI improvement = BI @ Acute_Hsp – BI @ Recuperative_Hsp. (Nakayamael al, 2012)

All patients Initial BI 0-50 BI 51-75 BI 76-1002008 19 26 20 62011 24 32 23 7

0

5

10

15

20

25

30

35

Length of Stay of CVA Patients (in days) before and after application of the pathwaywith the form at acute hospitals in southern Ibaraki (Nakayama et al, 2012)



Tsuyoshi Ogata is the Director of the Chikusei public healthcenter of Ibaraki Prefectural Government in Japan. He isengaged in public health administration, which includes thedirection of hospitals and community infection control.

He graduated from the University of Tokyo, school of medicinein 1981, and became qualified to become a doctor. He hadworked for a long time for Ministry of Health and Welfare,Government of Japan. In 1998, he became the Chief of Officeof Minamata Disease, Ministry of Environment in Japan. In2000 he moved to the Ibaraki prefectural government.

His specialty is in epidemiology and health crisis management.He earned a PhD at the Jichi Medical University in 2009 for thecontribution of reporting the first H5N2 avian influenza infectionto human.

His portfolio of work includes a Director and co-chairman ofpublic relations committee of the Japanese Association ofPublic Health Center Directors. He also works for the JapaneseSociety of Public Health as a Councilor and a member of theinfection control policy committee. He is a Councilor and amember of the public relation committee of Japan-ChinaMedical Association.



Building a Regional Agenda for Hospitals inIntegrated Health Service Delivery Networks

REYNALDO HOLDERREGIONAL ADVISER, AREA OF HEALTH SYSTEMS,WHO REGIONAL OFFICE FOR AMERICAS, WASHINGTON D.C., USA

With the renewed interest in health systems based on a PrimaryHealth Care (PHC) approach and thrust toward Universal HealthCoverage, it has been recognised that during the next decadehealth systems in general and hospitals in particular will have toimplement important reforms as health system integration takesshape. Continued changes in the epidemiologic anddemographic profiles, and increases in chronic diseases andageing will put greater demands on health care delivery servicesand require new ways of characterising hospital services.

In the Americas, the vast majority of health systems arecharacterised by high levels of fragmentation. Existingorganizational structures, management, and culture in hospitalsinfluence models of care that discourage integration and aremajor causes of poor performance in health systems. Thetraditional vision of the hospital as an "autonomous", self-contained entity placed above other health servicescomponents, and the lack of coordination between hospital-based services and other healthcare facilities is being widelycontested and new organizational models are sought to provideintegrated care.A strategy to address the fragmentation of health services wasadopted by the Governing Bodies of the Pan American HealthOrganization (PAHO) in 2009, through resolution CD49.R22 on

Integrated Health Service Delivery Networks (IHSDNs) basedon PHC, which recognised that “integrated health servicedelivery networks are one of the principal operationalexpressions of the PHC approach in health service delivery". Anumber of PAHO’s Member States have embarked on reformsbased on the IHSDNs framework. The changes or reforms havetaken the form of new legislation (Brazil, Colombia); building ofintegrated networks (Brazil, Chile, El Salvador, Uruguay);national health policies (El Salvador). governance bodies (ElSalvador, Chile), strengthening of first level of care (El Salvador,Paraguay, Uruguay) and on-going consultation processes inPanama, Peru and Uruguay.

Central to these changes, the IHSDN strategy proposes aremodelling of hospitals that emphasises the importance ofworking in networks with clear objectives towards outpatientcare, integration, co-accountability and participation. Thistransformation requires changes within the hospital’s identity aswell as in the relationships that it establishes with the otherhealthcare delivery facilities. Member States expectPAHO/WHO and other international organisations to examinethe situation and offer a vision for the development of hospitalsin the context of IHSDNs, in addition to focusing on andintensifying capacity building to support reforms in the hospital

Key Messages

The renewed trust toward Universal Health Coverage in building Primary Health Care based health systems possessthe challenge for healthcare delivery services in general, and hospitals in particular, to address and achievehealthcare integration.

Central to these changes, the Integrated Health Service Delivery Networks (IHSDNs) strategy proposes aremodelling of the hospitals that emphasises the importance of working in networks. This transformation requireschanges within the hospital’s identity as well as in the relationships that it establishes with the other healthcaredelivery facilities.

Hospital and healthcare managers in the Region of the Americas agree that:

1) Without hospitals there can be no IHSDNs;

2) IHSDNs will not be possible if the current organizational culture in hospitals is allowed to persists; and

3) Without IHSDNs the current problems and challenges of hospitals cannot be resolved.

These hospital and health services managers have a clear and common understanding of the problems andchallenges that need to be addressed, and share a common vision of the future of hospitals and what the hospitalof the future should be and do, and they propose straightforward recommendations on how to get there. Thechallenge is for Policy Makers to listen more closely.



sector in different countries. In response, PAHO/WHO isconducting a series of activities and events under the banner of“Building a Regional Agenda for Hospitals in IHSDNs”. Theobjective is to provide policy options to guide the futuredevelopment of hospitals in the countries of the region anddefine a road map for transformation within the context ofIHSDNs based on PHC.

These activities have included publications, studies, surveysand debates with health services and hospital managersthroughout the region.

Publications, studies and surveys:In 2011, the PAHO/WHO country office in Chile published theSpanish version of a book titled “Integrated Healthcare DeliveryNetworks: The Challenge for Hospitals” (the English version waspublished in 2012). This publication reflects the concerns, pointsof view and positions of the more than fifty health servicesmanagers and academics that co-authored the publication. Thebook raises many questions and its major contribution has beento bring the subject forward on the agenda and initiate a widedebate.

The publication establishes three propositions for debate: 1)without hospitals there will be no IHSDNs; 2) there will be noIHSDNs if the status quo of the current hospitalorganizational culture persists; and 3) without IHSDNsthe current problems and challenges of hospitals will notbe resolved.

In collaboration with the Andalusian School of PublicHealth (EASP), two studies were conducted to gatherinformation to nurture the debate: A SystematicLiterature Review on the Evolution and Trendof Hospitals and a Situation Analysis ofHospitals in Ten Countries of LAC. EASP wasalso requested to set up and host an onlinesurvey.

The systematic review provided evidence onhospital trends and the outlook for the hospitalof the future. On the other hand, the initialapproach for the situation analysis was toconduct structured interviews with keyinformants responsible for health services inministries of health of ten Member Statesselected using the World Bank classification ofcountries according to income level.EASP consultants visited each country and conducted face-to-face interviews structured around the four domains and 14essential attributes of IHSDNs10. . Key informants were alsoasked to complete an Excel file with information on public and

10 See, PAHO/WHO Integrated health Service Delivery Networks:Concepts, Policy Options and a Road Map for Implementation in theAmericas. Washington D.C. 2011 page36.

private hospitals in their respective countries, and to completean online survey. The countries selected were:

Interviews were completed in all 10 countries, however, somecountries were unable to complete the Excel file due to lack ofinformation on hospitals, particularly private sector hospitals, aweakness shared by many countries in the Region.Furthermore, some key informants either failed or declined torespond to the online survey. In order to expand the number ofqualified opinions for the situation analysis, invitations were sentout to hospital managers and other healthcare managers inother countries of the Region to respond to the online survey.

Meetings with Healthcare Managersand other Experts:These meetings took on two modalities. First a total of 28meetings were held involving over one thousand participantsfrom 30 PAHO/WHO Member States. In addition, two Experts

Meetings were conducted, with and overall participation of 120managers, academics and researchers.

Results:

Preliminary analysis of the information gathered for the situationanalysis and from the meetings with managers and experts

Progress



shows common problems and a shared vision of what Hospitalsshould be and do in the future.

The following box summarizes the recommendations ofmanagers and experts, based on the four domains of PAHO’sIHSDN framework that will shape the Regional Agenda forHospitals.

Dr. Reynaldo Holder, a citizen of the Republic of Panama, hasworked in the health sector for the last 30 years, including 24years in managerial/administrative and technical positions andeleven years of Pediatric practice. He is currently serving asSenior Advisor for Integrated Health Services with the PanAmerican Health Organization/World Health Organization inWashington,D.C. Dr. Holder is a specialist in organization andmanagement of health systems and services both at the nationaland local levels. He served for five years as Regional Director forthe San Miguelito Regional Health System in Panama, where heplayed an instrumental role in the design and implementation ofa new management scheme for the regional hospital and themodernization of the regional healthcare network. Dr. Holderalso worked as Technical Director for the North East Regional

Health Authority in Jamaica, W. I. before joining PAHO/WHO inMarch 2002. Since joining PAHO he has worked in Belize,Barbados and the Eastern Caribbean Countries. In 2007 he wastransferred to PAHO’s regional headquarters in Washington, D.C where he provides technical cooperation and support to allMember States.

He holds a Doctor inMedicine Degree from theInstituto Superior deCiencias Médicas de LaHabana, Cuba (1982); aMedical Specialist Degree inPediatric Medicine fromHospital del Niño, Panama(1988); and a Master inScience in Health ServicesManagement from theUniversidad Latina dePanama (2002).Dr. Holder is a member of

the American College ofHealthcare Executives, anAssociate Editor of theInternational Journal ofIntegrated Care and aFounding Board Member ofthe International Foundationfor Integrated Care.



Efforts towards Integrated Health ServicesIn The English-Speaking Caribbean

Dr. IRAD POTTERCHIEF MEDICAL OFFICERGOVERNMENT OF THE VIRGIN ISLANDS

Historical ContextThe Caribbean comprises countries belonging to four languagegroups: English, Spanish, French and Dutch. The countries orterritories of the English-speaking Caribbean (ESC) consist of15 island states and two continental countries (Belize andGuyana) which share a common historical, geopolitical andsocio-demographic context. These countries are predominantlysmall states with population ranging from 5000 (Montserrat) tothe two largest, Trinidad and Tobago and Jamaica, withpopulations of 1 328 000 and 2 660 000 million, respectively andhave a shared history. The majority of these countries haveachieved independence but some of them still exist as UnitedKingdom Overseas Territories.

The earliest organization of health services in the Caribbeanoccurred during the post-emancipation period of the early 1900sand was influenced by the high mortality rates from majorinfectious diseases [malaria, syphilis, tuberculosis, yaws andyellow fever]. The Caribbean benefited from the concern of thecolonial authorities who appointed a series of commissionsincluding the Rockefeller and Moyne Commissions and theIrvine Committee to investigate these diseases in the early tomid 1900s. Their research made recommendations thatrevolutionized health care services in the Caribbean.

The first half of the twentieth century brought two importanthealth care milestones to the Caribbean: the establishment ofthe West Indies School of Public Health to train public healthnurses and inspectors, and the establishment of the UniversityCollege of the West Indies to train doctors.

The health profile of the English-speaking Caribbean countriesis very similar to industrial countries. The main health problemsof adults are heart diseases, malignancy, cerebrovasculardiseases, diabetes, hypertension and road and traffic injuries.The English-speaking Caribbean are aggressively strugglingwith major environmental health issues of safe water supply,solid waste and sewage disposal, and pollution of the coastalwaters. Natural disasters and particularly hurricanes are alwaysthreats that cause injuries and economic losses due to theenvironmental damage and the cost of rehabilitation.

The major determinants of health care are the population sizeand structure, the health status and problems, existing andfuture health resources, and the development in medicaltechnology especially the high cost procedures.

The Caribbean countries’ acknowledgment that collaboration

Key Messages

The English-Speaking Caribbean countries share a common history and face similar health issues. The chronic noncommunicable diseases are the major causes of ill health and there is a growing burden of injuries and violence.

These countries have long acknowledged that collaboration and cooperation were needed to meet health challengesand improve health and so the Caribbean Cooperation in Health initiative was launched in 1984.

The challenge of providing the highest quality health care even in the smallest jurisdictions have led to several studieson shared services and the development of several regional health strategies and institutions.

Regional policy and action paved the way for the elimination of polio and measles and has realized progress towardsthe elimination of congenital rubella syndrome, congenital syphilis and vertical transmission of HIV.

As the Caribbean single market and economy progresses, more formal integration of health care delivery systemswill be realized as the economic and political integration deepens.



and cooperation were needed to meet health challenges andimprove PHC delivery gave birth to the Caribbean Cooperationin Health in 1984. The concept promotes collective andcollaborative action to solve critical health problems bestaddressed through a regional approach, rather than byindividual country action. The initiative was approved byCARICOM Heads of Government in 1986 when CCH Phase Iwas launched.

The initiative is currently in its third iteration.

Shared Services

Efforts intensified both in scale and scope with theestablishment of the Pan American Health Organization(PAHO) in 1948 and the Conference of Caribbean Ministers ofHealth in 1969.

The necessity for increasingly regionalised systems ofsecondary and tertiary care has been propelled byconsiderations relate to the issues of small population size,underdeveloped infrastructure, budgetary limitations and thechallenge of providing the highest quality health care even inthe smallest jurisdictions.

Several studies on Shared Health Services have beenconducted in the Caribbean. Options identified by thesestudies were enhancement of local capacity (facilities andskills) to deliver direct services or to accommodate visitingspecialists; establishment of a pool of mobile specialists,regional referral centres, and resource clinical departments tosupport local services; and utilisation of new technologies, e.g.telemedicine. Benefit was seen in an arrangement that allowedfor the transfer of tertiary care patients from the OECS to thelarger established centres in Jamaica, Trinidad and Tobagoand Barbados.

Successful Shared Experiences

Caribbean countries have adopted, accepted and repeatedlyconfirmed at the highest political levels of CARICOM theirconcern for and commitment to enhancing health opportunitiesfor all through the establishment of key institutions andcommon policy and strategic frameworks which allow for costsharing and greater effectiveness and efficiency in delivering ofHealth Care in the English Speaking Caribbean. These are: The Organization of Eastern Caribbean States (OECS)

established the OECS Pharmaceutical ProcurementService (OECSPPS) for the pool procurement ofmedicines and other commodities. A common formularyhas been established and by pooling to purchasemedicines they realize savings of over 30% over marketprices.

Travelling Medical Specialists eg., Psychiatristconsultant visits Montserrat ad Anguilla on a monthly basis

from Barbados to see patients through a Government toRegional Training Institution. With the private sector thereis a significant sharing of expertise to provide specialistservices in fields such as nephrology, urology andcardiology between the better resource states and thosewith less local capacity.

Regional Nursing Examination – CARICOM HealthMinisters have established the Regional NursingExamination which by agreement is required forregistration and practice in CARICOM Member States

Caribbean Association of Medical CouncilsCARICOM Health Ministers have established theCaribbean Association of Medical Councils Examinationfor trained medical practitioners who wish to practice withinCARICOM Member States. It aims to provide a regionalbasis of ensuring standards for the medical profession.

Caribbean Accreditation Authority for Education inMedicine and other Health ProfessionalsCARICOM Health Ministers have established theCaribbean Accreditation Authority for Education inMedicine and other Health Professions (CAAM-HP) todetermine and prescribe standards and to accreditprogrammes of medical, dental, veterinary and otherhealth professions education on behalf of the contractingparties in CARICOM.

CARPHA: - A Single Public Health Agency for theRegionAn Inter-Governmental Agreement signed by CaribbeanCommunity Member States established the CaribbeanPublic Health Agency (CARPHA) on July 2nd 2011. Thecreation of CARPHA signals a rationalisation of regionalpublic health institutions into a single agency to providereference laboratory, epidemiology and other public healthservices to member states.

Towards the Future

1. Regional Health Insurance Mechanism (RHIM)Freedom of Movement in CSME had implications for access tohealth services and for the associated cost and financing ofcare. Work is ongoing towards the establishment of a regionalhealth financing mechanism.

2. Caribbean Framework for Regulation of Medicines andHealth TechnologiesA Caribbean Regulatory System (CRS) is proposed, to performthe essential regulatory functions according to best practices inorder to protect the health of Caribbean people. The proposedscope for the regulatory system is Medicines and HealthTechnologies, including radio-active sources for medical use.Its implementation will be modular with priority for genericmedicines. The regulatory functions are also presented withproposed shared responsibilities at CARPHA and nationallevels.



Regional cooperation in health has been a catalyst forimproving the health of the people of the English SpeakingCaribbean. This has largely been facilitated by regional policyand action. Regional strategic initiatives have paved the wayfor the elimination of polio and measles and has realized mustprogress towards the elimination of congenital rubellasyndrome, congenital syphilis and vertical transmission of HIV.As the Caribbean single market and economy progresses moreformal integration of health care delivery systems will berealized as the economic and political integration deepens.

Bibliography

Allman-Burke, Grace (1986). Report of ConsultancyConcerning Study of Medical Referrals in the EasternCaribbean. USAID RDO/C

Banoub, Samir N. (1990). Integrating Health Care: Studyof Coordinating Health Services and Establishing ReferralCenters in the Eastern Caribbean States. Final Report.PAHO/WHO.

Cushman, Robert (1996). Shared Health Services in theOrganization of Eastern Caribbean States: SituationAnalysis and Potential Areas for Development. OECS

Dr. Irad Potter, a native of The Virgin Islands, attained theMB.BS degree from the University of the West Indies, in 1982,a Post Graduate Diploma in Child Health in 1985 and a MastersDegree in Public Health in 1987. Between 1987 and 1995 hehas held the posts of Pediatrician and Director of PrimaryHealth Care within the Ministry of Health in The Virgin Islands.During this time he served as focal point and programmemanager for several subjects including Maternal and ChildHealth, Nutrition, Epidemiology and the HIV/AIDS. In 1995 hewas appointed to the post of Director of Health Services a postwhich was renamed Chief Medical Officer in 2010.Dr. Potter continues to serve in that position in The PublicService. In his current position he is largely responsible foradvising on health policy and health planning andprogramming. Dr. Potter has participated actively in theregional health agenda for the past 26 years. Dr. Potter hasmaintained keen interest in health systems developmentlocally, regionally and globally.He currently serves as Chairman of the Steering committee forthe establishment of the National Health Insurance programmein the Virgin Islands. Outside of his official duties, he isinvolved in many community activities with a special interest inyouth development and sports (particularly basketball, littleleague baseball and softball).

Hospitals and Multi-morbid Chronic Conditions

INTERNATIONAL HOSPITAL FEDERATIONRoute de Loëx 151, 1233 Bernex (Genève), SwitzerlandTelephone: +41 22 850 94 20 / Fax : +41 22 757 10 16

[email protected] / www.ihf-fih.org

Progress and challenges on integrated care around the world

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