The success of restructure and re-engineering healthcare in SA by introducing NHI must be developed along the lines of an integrated, coordinated and collaborative delivery model and integration, coordination and collaboration by multiple stakeholders.

In low- and middle-income countries, it is easy to demonstrate the benefits of an integrated, coordinated healthcare strategy that takes the needs of the poor into account.

Integrated care is similar to coordinated care and is prefaced on a collaborative ideology. This is contraposed to fragmented and episodic care.

THREE PRINCIPAL DEFINITIONS:

1. A process-based definition. It is a model that creates connectivity, alignment and collaboration between the participants in the ‘care’ sector. The goal is to enhance quality of life, consumer satisfaction and systems efficiency for people, by cutting across multiple services, providers and settings. It is an interconnecting set of processes aligned with a continuous support process over time.

2. A User-led definition. Care determined by the people themselves.

3. A Health System based definition as used by WHO Regional Office in Europe. “Integrated Healthcare Services delivery is defined as an approach to strengthen people-centred health systems through the promotion of comprehensive delivery of quality services across the life-course. It is designed according to the multiple dimensional needs of the population and the individual. It’s delivered by a coordinated multi-disciplinary team of providers, working across settings and levels of care.”

The system is managed to ensure optimal outcomes and appropriate use of resources based on best available evidence. Important and entrenched in the concept is that it has, “feedback loops to continually improve performance and tackle upstream causes of ill health and it promotes well-being through inter-sectorial and multi-sectorial actions” [WHO].

Implicit in the definition is the notion that Integrated Health Services Delivery (IHSD) should be centred on the need of individuals, their families and communities. Two interrelated factors that are driving Integrated Care Delivery:

1. The growing prevalence of chronic diseases.

2. The population aging – placing a heavy burden on the Health Systems.

Chronic diseases are the leading causes of death and disability throughout most of the world. It now accounts for 75% of the Global Healthcare spend (likely to increase in the next few years). This aging population is associated with increased comorbidities, increased medication, increased modalities of care, increase hospitalisation and length of stay in hospital, resulting in increased costs.

Managing this group of patients and providing care is inadequate due to fragmented healthcare delivery, poor communication between practitioner and patients. The product of fragmentation results in ineffective care and often duplication of care. This is evidenced in South Africa. Compounding these challenges is that the “absence of a good interface between the health system and social services allows elderly patients to ‘fall through the cracks’ because neither side understands the full extent of the patients’ problems.

Care fragmentation also frustrates the patients who have difficulty in navigating multiple providers.” Importance with integrated care strategies is that is brings together different groups involved in patient care so that, from the patients’ perspective the services delivered are consistent and coordinated. Too often providers focus on a single episode of treatment, rather than the patient’s overall well-being.

There are three broad categories of integrated care:

1. Integrating Primary and Secondary Care. This is an attempt to provide ‘one stop shop’ service for patients, to improve care coordination, especially for people requiring long term care (who by definition include chronically ill and elderly patients) or to ensure more appropriate use of Healthcare services.

2. Integration between Healthcare and Community care. This is an effort to coordinate wide range of services including social services and community nursing services.

3. Integration between Payer and Providers. Efforts are designed to more closely coordinate care planning, commissioning and delivery. Payer and Provider integration makes it easier to ensure that incentives within the system encourage all providers to maximise care quality, while minimising costs. “When patients are managed in an integrated and coordinated manner with a closely coordinated follow-up care, it leads to decreased need of costly emergency interventions and significantly reduced risk of death.”

In low- and middle-income countries, it is easy to understand the benefit for an Integrated coordinated care strategy. The challenges are enormous: lack of skilled health professionals, lack of resources, fiscal constraints, the rise of infectious disease epidemics and the tsunami of NCDs, and lack of access to essential medicines and basic equipment as well as lack of access to care.

This is a challenge we have in South Africa as we plan to deliver Universal Healthcare via the NHI programme. Also there is a challenge to meet the SDGs by 2030. It will be prudent that as we prepare for 2030, we begin to create a platform for an Integrated Care model.

“The success for this will be a paradigm shift from how we tweak the present fragmented, unsustainable and inaccessible care model to a set of services where the primary goal is to improve management of basic healthcare and of chronic conditions by minimising hospital admissions and maximising care delivered in the community. This is achieved through primary care physicians, specialists, home nursing services and perhaps other community-based health professionals.”

MODELS OF INTEGRATION

1. Structural – different organisations or groups either merge or have some form of formal partnership or joint venture

2. Virtual – integration requires only that the organisations or groups work closely together.

Both cases, the best results are achieved through effective governance, strong performance management, value-based reimbursements and the evaluation of outcomes of care. A shift towards integrated care is usually a substantive change for a healthcare organisation. It must include good clinical leadership, good communication programmes, a clear and concise vision, and taking the entire team including the staff to understand and embrace this new way of thinking and understanding what the objectives are.

Care Coordination is not ‘One Size fits all’.

There are five care components of coordination in the literature:

1. Institute a team-based approach

2. Know the details of your population to effectively manage the population’s health risk. Need proper data systems, work flow data and expertise to analyse data

3. Expand access and relationships to include more than medical care.

4. Care now includes determinants on individual’s overall health. Prevention and treatment have moved beyond the hospital and office walls to pharmacies, urgent call clinics and retail centres.

5. Reimbursements – invest in individualised care

6. To obtain a return on investment organisations need to define and communicate their desired outcomes and measure performance against those outcomes and assure that processes are continuously adjusted for consistency with best practices. ROI in healthcare cannot be just the profits at the end of a balance sheet

7. Prepare for a shift to new payment models, driving towards Value-Based reimbursements. There are two approaches to improving healthcare, especially in the LMICs – vertical and horizontal programmes. It is better to have horizontal Health System Strengthening, rather than the isolated vertical programmes. In LMICs the horizontal platforms are not adequately strengthened. There is a need to strengthen the facilities, increase healthcare professionals and human resources, adequate IT platforms, availability of medication, healthcare management services and financial support.

Without this vertical disease specific programmes and selective programmes will not have a platform to work off. Often, donor and funded programmes focus on disease specific vertical programmes. They may be financially rewarding but may operate in silos, without necessarily improving all the areas of healthcare deficiencies. Primary Care itself must be a component part of the horizontal care platform. It must serve to strengthen the health system to support multiple vertical programmes.

This is a major undertaking and not a mere adjustment, it is a call for a, “Fundamental Paradigm Shift in the way health services are funded, managed and delivered.” NHI programme in SA will be successful if it embarks on an important and necessary horizontal approach of Health system strengthening with Primary Care firmly entrenched as part of the horizontal programme. The vertical focus will then incrementally deliver the other modalities of care to support the Alma-Ata Declaration and achieve the SDGs by 2030.

BYLINE: Prof Morgan Chetty, visiting Prof: Health Sciences, DUT chairman, IPAF, CEO: KZNDHC