|Year : 2013 | Volume
| Issue : 3 | Page : 166-168
Integration of healthcare programs: A long-term policy perspective for a sustainable HIV program for India
Sukarma S.S. Tanwar1, Bharat B Rewari2
1 Public Health Foundation of India, India
2 National AIDS Control Organisation, Government of India, India
|Date of Web Publication||14-Oct-2013|
Sukarma S.S. Tanwar
Public Health Foundation of India, National AIDS Control Organisation, 6th Floor, 36 Janpath, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
With the Government of India's initiative to ensure Universal Access to health through its flagship program of National Rural Health Mission, the debate on the economic efficiency and sustainability of a 'stand-alone' over 'integrated' programs has become extremely relevant. This study was conducted with the aim to establish opinion on the issue of sustainability of 'stand-alone' HIV program in India. Experts working on health policy development and implementation at various were interviewed on this issue and majority of experts interviewed were of the opinion that a 'stand-alone' HIV program is not sustainable in the long run because of inefficient use of resources. Integration of HIV program with the general health system is essential but it needs extensive planning. Areas like HIV testing centers, prevention of parent to child transmission and sexually transmitted infection diagnosis and treatment can be integrated with the general health system immediately.
Keywords: Convergence, General health system, Integration, NACO, NRHM, Parallel program
|How to cite this article:|
Tanwar SS, Rewari BB. Integration of healthcare programs: A long-term policy perspective for a sustainable HIV program for India. Indian J Public Health 2013;57:166-8
|How to cite this URL:|
Tanwar SS, Rewari BB. Integration of healthcare programs: A long-term policy perspective for a sustainable HIV program for India. Indian J Public Health [serial online] 2013 [cited 2019 Sep 17];57:166-8. Available from: http://www.ijph.in/text.asp?2013/57/3/166/119837
| Introduction|| |
In a country like India, where majority of the population lives in rural areas and even a 0.1% increase in the incidence of new infections can increase the population of HIV-infected people by half a million, it is important to have policies that can ensure consistent healthcare services to the maximum number of people, in the remotest of the areas.
The National AIDS Control Organisation (NACO) was established under the Ministry of Health and Family Welfare in 1992  to address the problem of HIV/AIDS. The focus during the first phase of the National AIDS control program, NACP-I (1992-1999) was mainly on HIV surveillance and related activities, screening of blood and blood products, and public education campaigns. During the second phase, NACP-II (1999-2006) the focus shifted to raising awareness and toward interventions promoting behavior change. In this phase the ART roll out was also done. In the third phase, NACP-III (2007-12) the focus was to halt and reverse the epidemic by 2012 by focusing on prevention efforts and integration of care, support, and treatment strategies.  Currently the fourth phase of the program is being formulated with the objective to accelerate the process of reversal of HIV and further strengthen the response to the epidemic through a cautious and well-defined integration process with increase in public-private partnerships. 
Parallel versus Integrated approach
Vertical program also known as a 'stand-alone' or a 'parallel' program is one where, interventions are provided through a delivery system that has a separate administration and budget or a different structural, funding, and operational integration with the wider health system. On the other hand, an integrated program has no separate administration or budget and interventions are delivered through existing healthcare facilities that provide routine or general health care services. It is believed to have focus on the priorities of the local people, the regional health services  and tends to bring services together with minimum wastage of resources.  It creates a single system for long-term solution by avoiding duplication of work and encouraging sharing of resources.  While discussing the health service delivery model, areas like governance arrangements, organizational structure, funding and method of service delivery also need clarity.  The various aspects that should be considered while taking a major policy decision like planning of integration with the general health system are: 
- Will Integration add value?
- Is it the right time?
- Is Integration possible (human resource, infrastructure)?
- Will it strengthen the health system?
- Is there a clear plan?
- Is there a system is place for monitoring the outcomes of Integration?
As a part of the study protocol, key themes / issues with respect to HIV Care Program in India were identified on the basis of an extensive literature review. This was then followed by 11 semi- structured interviews which were analysed using framework analysis method. With the aim to establish an opinion on the issue of sustainability of 'stand-alone' HIV program in India, following officials were interviewed in 2011: one senior officer and one program officer working with the NACO, one senior officer from the Ministry of Health Family Welfare, two senior officers from the National Rural Health Mission, one officer from NACO North East Regional Office, one Project Director of SACS, one senior officer from WHO, one senior professor from LSHTM and PHFI and a senior officer from the Clinton Foundation.
Delivery of HIV Care
All the experts interviewed were in broad agreement with the excellent work done by NACO but had concerns about the functioning of the department especially at the state level. Experts felt that the policies and perhaps the policy makers were rigid with little flexibility for regional requirements. The officers at state level also felt that there is need to have flexibility in guidelines in order to make interventions more effective. An officer said that "the process for the preparation of Annual Action Plan should be a continuous process with more participation from officers at the state level.0"
Involvement of general health system in HIV care
Experts felt the need for more awareness camps in collaboration with the local governments, medical colleges, local medical councils, and tertiary level institutions.
Experts also felt that involvement of hospital superintendents or senior doctors in the daily functioning and monitoring of the HIV care and treatment centers could help in improving the commitment of the hospitals toward HIV program. One of the experts said that "Small initiatives like monthly reporting to NACO through the Medical superintendent of the hospital could make a difference in attitude of the staff at the general hospital and could improve ownership".
Another expert said that to change the attitude of the staff members working at the hospitals they need to be oriented and trained. For this she said "there could be a 'Pre- service' followed by an 'In- service' education program. The HIV program should organise these trainings more often at the state level with the aim to orient interns, post-graduate students in various medical schools and doctors working in the private and government sector."
Discussing about the concerns, the experts discussed the possibility of HIV health service delivery related tasks being generalized (doctors and nurses trained in general medicine treating HIV-infected patients), since integration will require utilization of multi-skilled workers and transfer of duties from specialists to non-specialists.
Future mode for delivery of HIV care in India
All the experts were of the opinion that integration should happen but only in selected areas. They suggested that the departments that could be integrated with the general health system are department for prevention of parent-to-child transmission (PPTCT), sexually transmitted infections (STI), and integrated counselling and testing centers (ICTC). The process of integration of treatment services is a slow process and should be done in phased manner. From all the experts the message was very clear that integration should happen to an extent where the quality of decision making is not compromised. While emphasising the need for integration, one of the officers said that "it is the right of the patient to get treatment, at least for long-term illnesses under one roof".
Experts also said that we need to utilize resources carefully and reiterating the same, one of the experts also suggested that the program should function like other disease-specific programs under the department of Health and Family Welfare.
During interviews, the experts were of the opinion that Integration in specific areas should happen in order to make the HIV-program sustainable. Integration can lead to expansion of program activities and also increased capacity of health care workers to respond to people's needs.  In fact as discussed in a paper recently published, it was suggested that District AIDS Officer who is from the general health system can play an important role in co-ordinating the various HIV-related activities in a particular district  and plan them in collaboration with the general healthcare activities. In fact as per WHO, the five basic competencies that apply to staff working for patients with chronic disease are patient-centered care, partnering, quality improvement, information and communication technology, and public health perspective. 
During the interviews the optimal utilization of the Peripheral Health Centers which provide primary health care was also emphasized since they are best positioned to deal with a chronic disease like HIV. The concept of Link ART center was appreciated by the experts and one of the experts said that "this could be a major step toward integration of HIV treatment with the general health system if monitored closely."
Ideally vertical programs should be time limited after which they should be integrated to avoid negative spill over effects. Indefinite vertical programs are justified in fragile states, weak general health systems or in places where integration is not possible. 
Discussing the issue of introduction of a nominal user fee for financial sustainability for patients on HAART, the message was very clear that any type of user fee would be a deterrent toward adherence. Most of the experts felt that the patients are already spending on health. Also out of pocket expenses directly affect the levels of adherence to treatment especially in settings where people are generally from low socio-economic class. 
It is important that in order to establish an effective health care system in a country like India it is important that people in-charge of disease-specific health care programs recognize their strengths and weaknesses and frame policies in a contextualized manner.  The disease-specific programs and the general health system are working to help people get their right to good health and these programs would become far more affective and meaningful if they work in collaboration.
| Acknowledgment|| |
Welcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India and a consortium of UK universities' and all the experts who were interviewed.
| References|| |
|1.||Overview of HIV/AIDS in India. 2010. Available from: http://www.avert.org/aidsindia.htm. [Last accessed on 2013 Mar 3]. |
|2.||Strategy and Implementation Plan, 2006. In: Department of AIDS Control. New Delhi: Minsitry of Health and Family Welfare;2006. |
|3.||Gist of the deliberations of the meeting of Working Group on AIDS Control by Planning Commission. Ministry Of Health 2011. Available from: http://nacoonline.org/NACP-IV/. [Last accessed on 2013 Jul 10]. |
|4.||Atun R, Bennett S, Duran A. When do vertical (stand alone) programmes have a place in health systems. Geneva, Switzerland: World Health Organisation;2008. |
|5.||McKeown T. The role of medicine:dream mirage or nemesis?: United States: Oxford Blackwell;1979. |
|6.||Berman P. Selective primary health care: Is efficient sufficient? Soc Sci Med 1982;16:1054-94. |
|7.||Criel B, Kegels G, Van der Stuyft P. A framework for analysing the relationship between disease control programmes and basic health care. Trop Med Int Health 2004;9:A1-4. |
|8.||Kadri A, Kumar P. Institutionalization of the NACP and Way Ahead. Indian J Community Med 2012;37:83-8. |
|9.||Preparing a health care workforce for the 21 st century: The Challenges of Chronic Conditions. In: Organisation WH, ed. Available from http://www.who.int/chp/knowledge/publications/workforce_report/en/ date of accession 23 Dec 2011. |
|10.||Souteyrand YP, Collard V, Moatti JP, Grubb I, Guerma T. Free care at the point of service delivery: A key component for reaching universal access to HIV/AIDS treatment in developing countries. AIDS 2008;22:S161-8. Available from http://www.ncbi.nlm.nih.gov/pubmed/18664948 date of accession 2 Jan 2012. |