Integrated primary-secondary care system
Health service integration is seen by the World Health Organization (WHO) as an essential requirement to achieve Universal Health Coverage (UHC) (1). According to WHO, an integrated health service delivery is defined as:
“… an approach to strengthen people-centered health systems through the promotion of the comprehensive delivery of quality services across the life-course, designed according to the multidimensional needs of the population and the individual and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care… … with feedback loops to continuously improve performance and to tackle upstream causes of ill health and to promote well-being through intersectoral and multisectoral actions.” (2)
The definition itself reveals the multidimensionality of the integrated care system. As Figure 1 indicates, integration can happen across the level of care (such as primary, secondary or tertiary), between the building blocks of the health systems (service delivery, human resource, medicine and technologies, financing, health information or governance) and even across geography or time-span (3). Moreover, based on its nature, integrated care can be divided into (a) Organizational: different health service organizations are merged for care coordination, (b) Functional: non-clinical services are related integration (such as administration, electrical supply, etc.), (c) Service: different type or genre of service merged at facility level using a multi-disciplinary team, and lastly (d) Clinical: application of shared guideline and protocol to treat comorbidity or ensuring continuum of care (4,5).
Figure 1: Complexity of vertical integration within health systems
Integrated primary-secondary care system (IPSCS) is a part of vertical integration where the primary healthcare system is efficiently connected with the rest of the healthcare delivery system, but most importantly, with secondary care. Within the hierarchical structure of the health system, IPSCS can bring “closer-to-community services” within broader management (organizational integration) or provide the opportunity for functional, clinical, or service level integration (4). It opens the prospect for organized service delivery between primary care provider and specialist, leading to early detection of disease, improved quality of care, better follow-up, and patient outcome (6–10)—however—effectiveness of the integration varies by context and interventions (11).
Indian Health Systems in Transition
While high-income countries are already moving to integrated service configurations and delivery, Low-and middle-income countries (LMICs) have yet to significantly implement integrated care in their public health systems, mostly because of the complexities of implementation in a context where healthcare infrastructure and human resources for health are inadequate (1). For example, the Government of India launched the Ayushman Bharat (AB) program in 2018 to restructure the public financing for healthcare and service delivery mechanisms towards UHC (12). The AB program consists of two unique—but complementary—components: (a) the Pradhan Mantri Jan Arogya Yojana (PM-JAY) and (b) scaling up Health and Wellness Centres (HWCs) (12). PM-JAY is considered as the largest health assurance program in the world, providing financial protection for 500 million of the poorest and vulnerable individuals (13). Under this scheme, a family will be covered up to 500,000 Rupee (approximately 6,978 USD, considering the exchange rate of 71.65 Rupee = 1 USA on 2 January 2020) per year. This will cover approximately 1,393 procedures, including doctor’s fees, drugs, supplies, diagnostics, room charges, etc. However, these benefits are eligible for only secondary and tertiary care services (14).
While implementing PM-JAY, the national and state health systems of India are transitioning through several structural integrations. PM-JAY is administered by a separate National Health Authority (NHA) at the national level. However, the individual state retains the flexibility to implement the scheme through the State Health Agency (SHA). State governments must contribute 40% of the cost for running the program and are encouraged to merge state-funded insurance schemes with PM-JAY to enable expansion of the risk pool. All public secondary and tertiary hospitals are automatically included under PM-JAY. The private health sector has been integrated within PM-JAY by empaneling private hospitals based on defined criteria linked to specific service packages (15). Further, functional integrations are also evident within the PM-JAY scheme through the portability of services across states.
While implementing the AB program, the Government of India is establishing 150,000 HWCs to prepare the primary healthcare delivery system for the emerging epidemiologic transition (16). HWCs are located within 30 minutes, traveling distance from any community. HWCs will provide an expanded range of services that will be available, including—reproductive, maternal and child health, preventive and curative care for communicable and chronic diseases, and support for mental health, etc. (16). To make it as the first point of contact closer to the community, existing rural clinics—designated as Sub-centers—and rural and urban Primary Health Centers (PHCs) will be upgraded as HWCs to deliver comprehensive primary health care (CPHC) (17).
Since its launch till February 2020, PM-JAY has empaneled over 21 thousand hospitals, issued more than 12 million beneficiary cards, and provided financial support for 3.6 million beneficiaries (13,14). Simultaneously, over 30 thousand HWCs have been established by transforming 13,516 Sub-centers, 13,417 PHCs, and 3,076 urban PHCs (16). However, the critical link between primary-secondary care provision is still missing, as PM-JAY does not yet provide financial support at these primary level facilities, and the pathway of care continuum is still evolving beyond HWCs, owing to its early stage of implementation.
Rationale of the review
The progress on the two components of the AB program has been promising so far, yet some critical design challenges have been identified. The fact that PM-JAY will not cover primary care, it is even more imperative to plan strategies under AB to increase the accountability of HWCs to deliver CPHC so that people do not bypass preventive and promotive services offered by HWCs. This will limit efforts of secondary prevention and lead to increased care-seeking from secondary or tertiary care facilities. As the demand for service will increase, the overburdened secondary or tertiary care facilities will face issues with the quality of care. More importantly, increasing demand will jeopardize the fiscal sustainability of PM-JAY (18).
Thus, the role of HWCs is paramount in this case. As the first point of contact, HWCs are mandated to keep the population healthy through prevention strategies and extensive lifestyle counseling. This will contribute to a lower frequency of procedures or curative care events. Further strengthening of HWCs by focusing on the continuum of care—starting from early initiation of preventive care, judicious use of curative care, proper referral, follow up care, and educating the beneficiaries about PM-JAY—need to be prioritized (19). This calls for effective integration of primary and secondary care between HWCs and other secondary-level public and private providers within the AB program. Therefore, to enable implementation of IPSCS within the AB system, there is a need to identify design features that can be adopted within the healthcare delivery systems as part of AB to enable a sound linkage across different levels of service provision. Other existing structural deficiencies of the Indian health care delivery system—such as governance, stewardship, quality of care, and health system organization—will also impose additional layers of complexity. Thus, looking at the global best practices and experience of health service integration is the most pragmatic way forward.
Several systemic and scoping reviews were already conducted exploring the IPSCS—however—the majority of those studies were conducted in the context of developed countries (7,8,20–22). Some evidence from LMICs has already shown that vertical integration of primary and secondary care has a strong potential to increase access, reduce cost, improve quality and health outcomes (21,22). There is an insufficient exploration of critical aspects of design, implementation of strategies, and assessment of IPSCS models and consolidation of evidence from other LMICs. A scoping review of available evidence from LMICs will help to understand the design elements and integration processes that have been used to thrive an integrated care model for UHC. As no prior synthesis has been undertaken on this topic—exclusively—in the context of LMIC, scoping review is an appropriate method (23). The methodological plasticity of scoping review will allow us to evaluate a breadth of contents—including qualitative, quantitative, mixed-method studies, reports, and other grey literature—to map, organize, identify and report the current knowledge base from LMIC countries. This exercise will draw the attention of stakeholders and support in building momentum towards a systemic reform for IPSCS for health service delivery in India (24).