Integration

Integration has been defined as “the organization, coordination, and management of multiple activities and resources to ensure the delivery of more efficient and coherent services in relation to cost, output, impact, and use (acceptability).” (WHO HIV, Family Planning/Reproductive Health, Maternal Newborn and Child Health Technical Working Group, March 2011). The integration of health sector activities and the integration of health sector activities with activities in other sectors – such as water and sanitation, education, food security, agriculture, economic growth, microfinance, and democracy and governance – can potentially achieve high-yield gains for health.

Five Factors to Consider about Integration

• Country ownership of integration policies and processes is essential.
• Integration entails both benefits and costs.
• Integration requires local adaptation.
• Integration is feasible.
• Integration is challenging.

Recent Empirical Evidence and Further Inquiry about the Value of Integration
Recent empirical evidence about the effects of integrating programs in the health sector has been promising. One such example is the rigorous analysis of the health and economic development effects of a long-term investment in an integrated family planning and maternal, neonatal, and child health program in Bangladesh. Others include the USAID-commissioned Cochrane Review on the integration of family planning, maternal and child health, nutrition, and HIV services. However, further inquiry and more rigorous research designs are needed to guide programs.

Integration Scoping Tool
Decisions about how to integrate or judgments about the adequacy of existing integration efforts can be informed by periodic assessments of what is already occurring. The Integration Scoping Tool is illustrative and exploratory; it can be used in any “scoping exercise” that seeks to understand better the nature and extent of integration efforts in any country. The Tool comprises three elements:

• An overarching question for each of five functional domains (policy, program/organization, system support strategies, services, and health-promoting behaviors)
• A series of features or characteristics for each functional domain
• A determination of the extent to which the function is present: fully, partially, or not at all

Monitoring and Measuring Integration Progress

• To measure integration progress, begin with a logic model of what you expect to achieve.
• From among the many variables in your logic model, define a limited, manageable number of indicators to track progress.
• Develop a simple measurement plan.
• Implement the plan.
• Modify the program based on periodic reviews of progress.

Future Directions
U.S. Government country teams should consider embedding the monitoring of important processes and the evaluation of outputs and outcomes into programming for integration, and adequately supporting this work with the necessary budget and manpower, perhaps by leveraging funds from other partners with similar interests.

Antiretroviral Therapy and Antenatal Care Integration in Zambia Two models of antiretroviral therapy (ART) provision in public sector antenatal care (ANC) clinics in Lusaka, Zambia, were studied: active referral from ANC clinics to ART clinics vs. integration of ART provision into ANC clinics. The integration strategy doubled the percentage of treatment-eligible women initiating ART during pregnancy compared to the strategy of active referral to the ART clinic (32.9 percent vs. 14.4 percent; AOR 2.01; 95 percent C.I 1.27-3.34). The researchers concluded that the provision of ART in ANC is feasible in resource-limited settings, although it may require greater investment in laboratory capacity, drugs, and adequately trained staff. To improve retention, the researchers planned to keep women in the integrated clinic until weaning, at approximately 6 months postpartum. Source: Killiam, AIDS 2010;24(1):85-91 and USAID Cochrane 2010 (study rigor was good, step-wedge evaluation design used)

More Resources

• GHI Principle Paper on Integration in the Health Sector [PDF, 1.2MB].  
• Download the printable PDF of this page [PDF, 62KB].