In the past decade we have witnessed a noticeable zigzag internationally on how to improve health system performance. While some have advocated for the primacy of primary health care (reinforced by a major 2008 WHO report), others have stressed the importance of hospital autonomy initiatives.
This zigzag clearly illustrates another false dichotomy in the health sector that merits urgent revision. More and more, we’re recognizing why a cohesive and integrated health care delivery model needs to be in place to better organize and respond to the changing needs of the population, particularly given the raising importance of noncommunicable diseases and injuries as the main causes of death and disability worldwide. A recent report on NCDs in China demonstrates how the chronic nature of these conditions—different from acute episodes of ill health resulting from infectious diseases—demands a well-coordinated combination of hospital, ambulatory and physician response, in some cases over the lifetime of an individual.
We need to take technological and financial imperatives into account, too. For example, procedures that used to require lengthy hospitalization now can be performed in an outpatient facility, thanks to new technologies with more convenience and safety for the patient. The financial realities across the world demand reductions in the avoidable costs of untimely, uncoordinated, expensive and substandard care.
How can we support the development of integrated care? Evaluated experiences in countries provide evidence: Kaiser Permanente and the Veterans Administration models in the United States; Trafford, a Greater Manchester borough of 215,000 people in England; the Chuvash Republic in Russia; the evolving privately run health management organizations model in Georgia; and more recently, the promising wider health care network established in Lesotho, a small country with significant health challenges in Africa.
These experiences show how the integrated care model embodies community-based primary, general acute medicine, specialist outpatient and diagnostic care, and referral hospitals.
The core of the model should be planned care in accordance with each population’s health needs. Integration is realized either through “vertical integration” of public facilities by developing agreements with unified goals and incentives, or “virtual integration” through contracting modalities that link public and private insurance companies and service providers. The critical enabling tools are de-concentrated or decentralized decision-making and management structures and processes, as well as the use of evidence-based clinical protocols to guide care coordination; health management information systems to coordinate the on time flow of patient and administrative and financial information across facilities; and new incentive frameworks that link resource allocation or payments to the production of quality services and good health outcomes.
Perhaps the time has come to ditch commonly accepted dichotomies and embrace more cohesive delivery system approaches by putting patients’ needs at the core of our work.