The conceptual understanding of health and its determinants – social, economic, environmental, commercial, and more – is constantly evolving. Health systems are expected to be responsive to these multifaceted health needs. In addition, the interconnected nature of human health, animal health, planet health, and environmental health has led to the widely accepted concept of One Health.
The unregulated, provision of healthcare services and goods has resulted in highly fragmented health systems, encompassing a mix of public and private, modern and traditional, formal and informal, and in-person and online services. Many vertical programs – such as those for mother & child health, tuberculosis elimination, HIV control, and polio eradication- have emerged in response to the Millennium Development Goals and donor funding.
At the dawn of India’s independence, a three-level health system– comprising primary, secondary and tertiary care–was envisaged. However, hospital-based care soon became the dominant mode of healthcare delivery, often at the expense of public health and primary care. Consequently, the care of non-communicable and other chronic communicable diseases became highly fragmented and discontinuous, leading to poor health outcomes.
There is growing recognition of the significant impact that various non-health determinants have on people’s health status. Additionally, it is acknowledged that communities can play a vital role in improving their own health status. While health systems have traditionally focused more on individual diagnostic and therapeutic healthcare needs, population-level interventions can yield greater impact. As a result, public health, distinct from person-focused healthcare, has assumed greater importance.
Hence, there is a pressing need to integrate fragmented health and social systems for efficient and effective management of health. While this need is acknowledged by all stakeholders, systems have struggled to put these needs into effective policies and actions. The integration of public health and primary care functions is being pursued as part of a comprehensive primary health care (PHC) systems framework. This framework envisions horizontal integration between public health and primary care and vertical integration between different levels of care. Within each level, there is a need for integration between public and private providers, public and private payers, and modern and traditional systems.
There is a need to coordinate health and non-health systems that directly or indirectly have a bearing on health status. Additionally, coordination and information sharing between systems responsible for human, animal, plant, and environmental health are essential to uphold the principle of One Health. Many countries provide valuable from their integration efforts, but these must be evaluated within specific national or subnational context.
Countries, including India, are leveraging digital information and communication technologies to achieve integration. India has adopted a minimalistic essential digital data stack approach, assigning unique IDs to individuals and entities, standardizing and making data interoperable, ensuring data privacy and security by design, using federated data storage, and integrating applications through open API systems. This approach, which has already transformed social, financial, and taxation sectors, is now being implemented in the health sector through Ayushman Bharat Digital Mission (ABDM). Other countries such as Estonia, Scandinavia, Canada, South Korea, Taiwan, and China are in various stages of advancing this process.
The World Health Organization (WHO) has provided a comprehensive primary health care (PHC) framework to integrate public health and primary care functions, promote interdepartmental coordination, and integrate communities with health systems. India is implementing this PHC framework through more than 160,000 Ayushman Arogya Mandirs (formerly known as health & wellness clinics) and over 1 million Accredited Social Health Activists (ASHAs). Various vertical programs, previously siloed and focused on maternal care, childcare, child care, vaccination, tuberculosis control, HIV control, malaria control, and NCD control are being integrated at the PHC level.
Multi-disciplinary care pathways have proven highly effective for managing chronic diseases, ensuring continuity across different levels of care and a variety of providers. However, implementing these pathways is very challenging in a mixed health system. Payer-driven models, such as value-based care, are emerging in many countries to facilitate integration through financial incentives. In the US, Accountable Care Organizations (ACOs) are being piloted to ensure integration between hospital-based and primary care providers by creating care networks.
Interoperable personal health records (PHR) are essential for integrating health information and, consequently, fragmented health systems. Countries are using both incentives and regulatory levers to encourage adoption across health systems, including, providers, payers, suppliers, public health professionals, health researchers, policy makers and, administrators. In India, initiatives like the Unified Health Interface (UHI) and Health Claims Exchange (HCX) are being tested to facilitate integration.
Robust governance and institutional mechanisms are needed to enable and sustain integration. Efforts include forming inter-ministerial groupings, multi-stakeholder health councils, and community participatory local governance systems. Community and private sector engagement are vital functions for governments at various levels. Transparency and trust in governance systems are essential for gaining agreement from various actors on integration.
In conclusion, health systems that aim for integration will become stronger, more secure, and resilient to respond dynamically to changing health needs both in normal and crisis times.
Dr. N. Krishna Reddy,
President, InOrder- The Health Systems Institute
Photo Credits: HT Mint