Integration of Services Across the Life Cycle
In addition to analyzing health care by level and function, DCP2 presents information about efforts to integrate care by stages in the life cycle. Newborns, children, adolescents, and women of reproductive age all have clusters of risks and conditions that can be addressed most effectively through access to an appropriate range of preventive measures and treatments. Chapter 4 addressed maternal and neonatal conditions. This chapter focuses on some of the DCP2 chapters that address integrated care for specific age groups.
"Integrating the management of childhood illnesses involvesimproving health workers' performance,health systems, andfamily and community practices."
Integrated Management of Childhood Illness
Following the neonatal period, deaths among children to age five are concentrated among those who suffer from diarrhea, pneumonia, malaria, and other infectious diseases and from malnutrition.8 Because comorbidity is highly prevalent and effective interventions are available, efforts have been made to integrate attention to children. The foremost initiative for this is the IMCI program, launched by WHO and the United Nations Children's Fund in the mid 1990s and implemented in dozens of countries since that time.
Integrating the management of childhood illnesses involves three components: improving health workers' performance, improving health systems, and improving family and community practices. The first of these includes training in the use of a treatment guide that instructs staff to look for danger signs, make thorough assessments, and then implement the appropriate case management interventions. The training also instructs health workers to integrate preventive and curative care by, for example, checking that children who are brought to a facility with a respiratory illness are current with their vaccinations and are adequately nourished. Second, integrated care of the child requires improvements in the health system to ensure that drugs are available, supervision and training are effective, referral services are functioning, and health information systems are in place. Third, improving family and community practices requires support for good breastfeeding practices, better nutrition, attention to hygiene, use of bednets, administration of fluids during an illness, and appropriate and timely care-seeking behaviors (figure 6.1).
[Figure
6.1]
"in Tanzania,districts that implemented IMCI spent the same or less per child as districts with traditional health care programs but achieved better care and a 13 percent reduction in mortality."
Evaluations of the IMCI program demonstrate, above all, the difficulties of implementing an integrated strategy of training, health system strengthening, and community involvement in countries with limited resources and weak public institutions. Most of the countries that have formally adopted IMCI have not fully implemented it. Of its three components, the one most successfully implemented is training workers. One of the better implementations was in Tanzania, where districts that implemented IMCI spent the same or less per child as districts with traditional health care programs but achieved better care and a 13 percent reduction in mortality (see box 6.4). However, the promise of integrated care has not been realized in most places because insufficient resources have been applied to implementing the strategy; health systems have been unable to provide the required personnel and managerial support; and no country has fully succeeded at linking IMCI to changes in family behaviors related to caring for illnesses at home, seeking care when appropriate, and improving nutrition practices.
School Health and Nutrition Programs
Schoolchildren are another well-defined subgroup whose health conditions cluster around a manageable number of illnesses and risk factors.9 Their school attendance creates a simple opportunity for reaching children through preexisting infrastructure. Furthermore, most low-income countries have more teachers than nurses. Thus the incremental cost per child of health interventions at schools is exceptionally low, amounting to less than US$1 per year for the simplest package. Targeting schoolchildren can be a cost-effective approach to delivering health interventions.
"While traditional medical practice emphasizes treatment after diagnosismass delivery of services, such as deworming and micronutrient supplementation, is often preferable on technical, economic, and equity grounds"
Health interventions at schools also complement their educational mission because good health and nutrition are prerequisites for effective learning. For example, deworming programs have been successfully implemented through schools and have subsequently improved attendance and educational achievement. Concomitantly, education is an important component of many preventive health programs, such as teaching children the importance of proper hygiene, road safety, use of bednets, and nutrition along with messages about sexuality and associated health risks.
An important element of this approach is a focus on minimizing the need for clinical diagnosis. While traditional medical practice emphasizes treatment after diagnosis, the new approach suggests that mass delivery of services, such as deworming and micronutrient supplementation, is often preferable on technical, economic, and equity grounds to approaches that require diagnostic screening.
Adolescents and Young Adults
Mortality rates among adolescents tend to be low relative to those for other age groups.10 Most of the disease burden is associated with depression, road injuries, and falls. Nevertheless, adolescence is a critical period for adopting or avoiding behaviors that increase the risk of illnesses in later years. Risk factors that often begin in adolescence include smoking, excessive use of alcohol, poor eating habits, subjection to sexual abuse, and unprotected sex.
"Risk factors that often begin in adolescence include smoking, excessive use of alcohol, poor eating habits, subjection to sexual abuse, and unprotected sex."
In Sub-Saharan Africa, the HIV/AIDS epidemic makes intervention in this age group particularly important. In this region, 63 percent of DALYs for young women age 15 to 29 are related to sexual and reproductive illnesses. Patterns of early marriage to older men and unprotected sex greatly increase a girl's chances of contracting HIV/AIDS and other sexually transmitted infections.
Interventions for adolescents are often difficult, because most risks at this age are not simple to address with preventive or curative care. They involve changing risky behaviors that may actually be encouraged by either traditional or modern mores. Generally, interventions need to give young people the information and skills for making good decisions; provide them with a range of health services that help them act on those decisions, such as contraceptives; and construct a social, legal, and regulatory environment that supports healthy behaviors and protects young people from harm, such as banning tobacco advertising.
Relatively few programs focused on adolescents and young adults have been implemented on a large scale. The most widespread programs focus on sexual and reproductive health, including prevention of HIV/AIDS. Of these, school-based programs are the most common. Nutrition, mental health, and tobacco prevention programs aimed at adolescents are more common in high-income countries. Services are often divided among various programs. For example, teen pregnancy may be addressed as part of an NGO's family planning program, while the ministry of transportation promotes road safety and a maternal health intervention promotes good nutrition.
"Interventions for adolescents are often difficult, because[t]hey involve changing risky behaviors that may actually be encouraged by either traditional or modern mores."
As yet, little has been documented regarding the costs or effectiveness of national health initiatives for adolescents and young adults. In Bangladesh, the Newlyweds Program has encouraged low fertility among recently married young people. New Zealand has established a program for preventing suicide among adolescents. Mongolia has introduced sex education after the third grade in response to rising STI rates attributed to early debut of sex, sexual violence, and exploitative messages in the media. South Africa's Love Life initiative has promoted sexual health and healthy lifestyles among 12- to 17-year-olds. Assessments of the South Africa program have found raised awareness of health risks, delayed debut of sex, fewer partners, more assertive behavior regarding condom use, and better communication with parents about sex.
Implementing such programs requires coordinating a complex range of interventions. In addition, the responses to the risky behaviors that are targeted may conflict with the goals of the government and the views of religious leaders, parents, or teachers. Some of the key principles in developing an integrated approach to this age group are to involve them in the process of program design, engage them as peer educators, make health services appealing and welcoming, and confront gender inequalities.
In sum, interventions are more cost-effective if they are implemented by a functioning health system and no interventions are helpful unless they are delivered. This section has discussed some of the issues that arise in organizing health care services by level, function, or around the needs of particular age groups. In general, DCP2 shows that these facets of the health care system function best when they are linked and can provide a continuum of care with appropriate staff and in appropriate locations. This in turn requires systems for generating and exchanging information, managing quality and staff, and mobilizing and allocating funds.
Notes
1 This section is based on DCP2, chapter 56.
2 This section is based on DCP2, chapter 64.
3 This section is based on DCP2, chapter 65.
4 This section is based on DCP2, chapter 66.
5 This section is based on DCP2, chapter 67.
6 This section is based on DCP2, chapter 68.
7 This section is based on DCP2, chapters 4, 6, 55, and 72.
8 This section is based on DCP2, chapter 63.
9 This section is based on DCP2, chapter 58.
10 This section is based on DCP2, chapter 59.
