INTEGRATION makes sense, but HOW?

This is the second post of a three part series of guest blogs based on writings provided by Maurits van Pelt, Director of MoPoTsyo Patient Information Centre in Cambodia. Collectively these writings will provide a roadmap for scaling up peer educator networks and developing sustainability for what is now still an intervention organized and facilitated by a Cambodian NGO. Part 1 focused on developing a Niche and Demonstrating value. Part 2 Focuses on Integration. Maurits van Pelt.

INTEGRATION makes sense, but HOW?

Recognizing the cost effectiveness of the Peer Educator Networks (P.E.N.), the Cambodian Ministry of Health recently approached MoPoTsyo to have the benign neoplastic P.E.N. become more integrated into Cambodia’s primary health care system. This could increase MoPoTyso sustainability by getting government network costs not yet recovered through revenues generated from service provided to members, as well as lead to better access to medical services for patients outside the scope of the Networks. However, what does such integration mean in practice?

Challenge 1: Can peer educators carry out new tasks?
Access to additional medical services can be critical in an environment where diabetic peer educators are untrained and unqualified to provide services outside their own chronic disease. It should be noted these educators are not community health workers and may easily overlook signs of other health problems that need priority attention. Consequently, much of the added value of Peer Educators will be lost if peer educators delay proper care instead of facilitating it.

Challenge 2: Linking various programs at the lowest is hard to do.
Patients often require horizontal functional linkages at the lowest levels of the health system with the National Mother- and Child Health, Neonatal Health program and Communicable Disease program. Unfortunately, many low income countries are notorious for problems with linking these kinds of different programs. However, these turf wars are mainly waged at the top of the program silos where policies are set for allocating resources. Fortunately, at the point of service delivery, patients and staff have different worries and offer little or no resistance to a more integrated approach provided the right conditions are in place.

Challenge 3: The current system may not have the capacity to satisfy consumer needs.
When preceding this integration, service capacity and availability can be a severe constraint. In other words, it makes no sense to train people in doing something if the conditions are not in place for delivery. For example, there are many barriers that delay seeking of professional care: transportation costs are relatively high and trust in public health services is generally low. If a peer educator recommends a patient to go for medical consultation many patients simply will not follow the advice because of real or perceived barriers.

MoPoTsyo’s approach to the challenges: Let’s pilot test at implementation level
Solutions for these technical challenges must be found that work in the local context. With the decentralization of the health system under way, it is likely that these horizontal and diagonal linkages are best piloted at the implementation level. After all, "how to brew the best soup collaboratively and steadily over time as it must be eaten locally". As an example, MoPoTsyo has an opportunity to strengthen the system’s ability to target subsidies to individuals and households who are most vulnerable in order to help them adhere better to prescribed treatment and cope better with the cost of their chronic illness. A voucher system is being piloted in the urban slums starting in July 2011 and can be rolled out to 4 provinces in the 4th trimester of 2011 if the results prove satisfactory. However, a broad regulatory framework for the operational district level is now required that captures the Peer Educator Network to become incorporated under the primary health care system. This can shift specific management tasks to local health authorities in exchange for proper rewards for their extra work and added responsibilities without clipping the wings of the Peer Educator Networks.