The Convergence of Infectious Diseases and Noncommunicable Diseases Proceedings of a Workshop (2019) / Chapter Skim
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7 Integrating Health Care Delivery Models and Interventions
7 Integrating Health Care Delivery Models and Interventions
Pages 77-96
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From page 77... ...
The session was moderated by Marcos Espinal, director of communicable diseases and health analysis at the Pan American Health Organization. The first presenter was Miriam Rabkin, associate professor of medicine and epidemiology at the Mailman School of Public Health, Columbia University, and director for health systems strategies at ICAP Columbia, who discussed how the scale-up of HIV services can be leveraged to provide NCD services in health systems.
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From page 78... ...
HIV AND NONCOMMUNICABLE DISEASE INTEGRATION PLATFORMS Miriam Rabkin, associate professor of medicine and epidemiology at the Mailman School of Public Health, Columbia University, and director for health systems strategies at ICAP Columbia, explored how the scale-up of HIV services can be leveraged to provide NCD services in health systems. Rabkin described ICAP's work on HIV, which has been a primary focus of the global health center and aims to deliver transformative solutions to strengthen health systems around the world through projects in more than 30 countries.
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From page 79... ...
. The first lesson is to use the public health approach to deliver services at scale through delivery mechanisms and platforms that do not require specialist physicians and academic health centers, she noted.
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. Integrating Noncommunicable Disease Services into HIV Programs To illustrate how NCD services might be integrated into HIV programs, Rabkin described the HEART study, an example of implementation science research carried out in Eswatini, also known as Swaziland.
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From page 81... ...
. The HEART study sought to explore the feasibility and acceptability of introducing CVDRF screening for people living with HIV into a busy HIV treatment clinic.2 Additionally, the study compared integrated management of CVDRFs -- with the HIV provider managing both HIV and CVDRFs during HIV clinic 2 CVDRF screening for patients aged ≥ 40 years receiving antiretroviral treatment included blood pressure measurements to detect hypertension, point-of-care HbA1c tests for diabetes, point-of-care cholesterol test, and tobacco history.
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From page 82... ...
The study randomized those who screened positive and collected data using screening results, exit interviews with screened patients, time-motion studies, key informant interviews with health care workers, and key informant interviews with patients randomized to integrated versus referred management. Screening was high yield, with 39 percent of almost 1,800 people screened having at least one CVDRF (primarily hypertension)
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From page 83... ...
Kimaiyo traced AMPATH's journey from its origin in 2001 with a nascent HIV care program in two clinics in and around Eldoret in western Kenya. In 2008, AMPATH expanded its focus to include chronic diseases and primary care, and in 2010, a memorandum of understanding was signed with the ministry of health in Kenya to work on NCDs (Bloomfield et al., 2011)
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From page 84... ...
. In Uasin Gishu a population health model is providing comprehensive community- and facility-based screening and care to achieve universal health coverage (Kimaiyo, 2019)
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From page 85... ...
Implementation science is an existing approach to studying how well delivery models perform, their uptake, and their barriers to uptake (Bauer et al., 2015)
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From page 86... ...
Bukhman described this new epidemiological phase as "all tail." He said that these outcomes were largely achieved through community-based interventions that were not contingent on a strong health system or functioning health centers. Achieving a population health effect requires thinking managerially and operationally about how to integrate services through clustering, he emphasized.
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From page 87... ...
Bukhman maintained that moving toward a new science of integration would help to provide operational clarity and to link up evidence-based interventions, health-sector priority setting, and implementation. He offered a provisional definition for the science of integration in global health delivery: "the study of delivery model design, including optimal clustering of tasks among providers, and interfaces within and outside of the health system." A first step in developing an integration science is to define what is being optimized, such as equity, cost-effectiveness, and/or financial risk protection.
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From page 88... ...
Ongoing Work in Integration Science In many systems, an initial goal of complete coverage of complex chronic care service packages at the district-level hospitals is achievable in the short term, noted Bukhman. WHO has a Package of Essential Noncommunicable Disease Interventions (WHO PEN)
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From page 89... ...
Proctor Foundation faculty member at the University of California, San Francisco, discussed the mass administration of antibiotics to reduce child mortality. She described how this integrated intervention emerged out of mass administration campaigns to prevent blinding trachoma.
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From page 90... ...
Oldenburg explained that during the early stages of some azithromycin trials for trachoma, there were questions about possible spillover effects of mass azithromycin administration, particularly on infectious burden in children. Studies that have looked at the effect of mass administration of azithromycin on diarrhea, malaria, and respiratory infections in children have generally shown positive results (Coles et al., 2011; Oldenburg et al., 2019)
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From page 91... ...
Therefore, it is best to treat all children under 5 years in order to maximize the number of people that benefit, she said. Mass Administration and Antimicrobial Resistance Oldenburg described the results of a systematic review of adverse events following mass azithromycin for trachoma control, which looked at all of the evidence of antimicrobial resistance (O'Brien et al., 2019)
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From page 92... ...
Targeting and Scaling Up Mass Administration Mass drug administration works where there is a large burden of disease, said Oldenburg. Global child mortality rates are changing fairly rapidly over time, so consideration of where to implement mass administrations needs to be informed by the background mortality rate of the setting -- for example, selecting geographic regions with more than 100 under-5 deaths per 1,000 live births (Golding et al., 2017)
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From page 93... ...
Bundling HIV Services with Noncommunicable Disease Services Espinal opened the floor for questions. First, Emily Erbelding, director of the Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Diseases, commented that The President's Emergency Plan for AIDS Relief (PEPFAR)
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From page 94... ...
Rachel Nugent, vice president for the Chronic Noncommunicable Diseases Global Initiative at RTI International, remarked that the mechanism of mass drug administration becomes less effective as the disease burden declines and disease reservoirs shrink to progressively smaller areas. She asked about the potential benefit of bringing NCDs into existing surveillance mechanisms to better understand co-occurrences within specific populations.
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From page 95... ...
Bukhman stated that external funding needs to increase because the poorest countries simply do not have sufficient domestic resources. Chronic care integration presents an opportunity to galvanize global health solidarity around more severe diseases affecting children, then disaggregating the argument and explaining that chronic conditions are also within the remit of global health responsibility based on those same premises.
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From page 96... ...
Kimaiyo remarked that even in a country that has adequate domestic resources, the government's management of those resources can be challenged by corruption, political pressures, or poor prioritization of funding. A new USAID initiative called the Journey to Self-Reliance is trying to support and strengthen governments' management capacities.8 Person-Centered Approach to Integration Finally, offering her perspective as the former minister of health in Peru, a middle-income country, arcía emphasized the need for changes in mindset G on three fronts.
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