Operational Pathways for Integrating National Disease Control Programmes for Universal Health Coverage

A mix-methods study was conducted to identify operational pathways for integration of national vertical programs under the UHC mandate in 7 Indian states. Background:Universal Health Coverage (UHC) is a widely shared global health agenda. WHO estimates that 20-40% of health budgets globally are wasted on system inefficiencies that range from de-motivated health workers, fragmentation, duplication of services, and inappropriate use of medicines and technologies. India currently has 13 national disease control and 2 health promotion programs to address primary healthcare delivery.From a practitioners perspective this report examines within the context of the Indian health system: 1) The role of Centre-State dynamics in program integration and design 2) Is integration desirable (will it add value) and opportune to strengthening weak health systems? 3) Indicate under what circumstances vertical and horizontal programs have a role in health systems and factors policy-makers must take into account when implementing vertical programs and managing integrated servicesObjectives: 1) To assess perceived levels of integration among disease control programs currently under the NRHM in India. 2) To identify operational pathways of integration of various disease control programs within a framework of UHC.Methods: The study incorporates mixed qualitative and quantitative methods with purposive sampling of 125 key informants with equal representation from the government, professionals and civil society. Phase 1 of the study involved desk review to document the history, architecture, and networks among preventive and promotive programs, both at the central and the state levels.Phase 2 resulted in development of a scale to identify and measure the level of integration of national disease control programs. To better clarify the depth of integration within programs five distinct levels demonstrating degrees (or extent) of integration were synthesized and measured according to the number of program components involved. In this scale, various program components correlate with increased levels of integration. A tool was developed to measure the informant’s perception on the level of integration of the disease control programs under the NRHM. Responses were analysed and scored to identify the level of integration among and within programmes and the number of components involved.Results: Our study indicates that the word ‘integration’ has varied interpretations at different levels. Discordance in definitions of integration has led to the concept being used loosely with the terms coordination, collaboration, convergence and cooperation used inter-changeably. Evidence through key informants identified several advantages as well as some drawbacks of programme integration in creating people-centered health systems; and recognized current barriers to integration while providing measures to overcoming them. State-centric models were exemplified in determining various operational pathways to effective integration. Review of integrated programmes shows that their effectiveness, and the factors that facilitate or impede success, depend substantially on the context in which the intervention takes place. Attempts to integrate programmes cannot therefore be seen as separate from their service delivery, geographic, financial and policy contexts. Although the autonomy of individual jurisdictions have been sacrosanct in public health, extending this principle to the design and implementation of the country’s disease control programmes has created challenges in conceiving a workable national health system. On the ground, a programme’s context, organizational capability of a health system and political clout of policy makers eventually influenced the extent of horizontal and vertical integration within and between programmes and ultimately determined solutions for efficient programme design. Integrating programmes will involve using alternative design elements through joint planning and capacity building before they are eventually rolled out at the national and state level. The one-size-fits-all norms and design of many national programmes impose inefficient restrictions on states and annual state plans for programmes are made in a routine manner without consideration for the widely varying requirements of states. Though programme stakeholders from different professional affiliations had different interpretations of the term ‘integration’, overall, the perceived benefits of integrating programmes at Central and State levels to form coordinated networks that contributed to better quality of care for individual patients, improved population health outcomes and reduced costs was unanimously recognized.Both vertical and horizontal approaches to program integration can be beneficial in different contexts and can coexist in health systems. In the long term, the limited evidence base, highly varied contexts and differences in health system capacity call for a pragmatic approach to programme integration rather than reactionary approaches driven by vested interests.