The ICP Grid results varied; Slovenia has the highest overall score (3.7) and Cambodia the lowest (2.1). While the total score is higher for Belgium as compared to Cambodia, we note that Belgium had a minimum score of 0 in one of the elements (Health Education); this was 0.8 for Cambodia (their lowest score).A more nuanced analysis per country is found in the D2.2 Situational Analysis Report.
The three country CoCs were similar in that, at the end of the care continuum, only a minority of patients are well-controlled. However, the cascade step where the largest losses are, differs. In Belgium, the largest gap is between prevalence and diagnosed. In Cambodia, a large drop is found both at the beginning and at the end of the cascade. In Slovenia, the largest attrition is at the beginning of the cascades (limited number of patients tested and linked to care).
Relative to the cost of scale-up, only Cambodia performed cost-modelling of implementing an integrated care package (submitted for publication, International Journal of Integrated Care SCUBY Special Issue).
For barriers and facilitators of scale-up of integrated care for DM and HT, the Cambodian health system faces a number of limitations, including human resources, financing, HIS and fragile community linkage, despite having a supporting structure.
In Slovenia, the overall health system and patient care is considered to be well-performing; nevertheless, there is still for improvement. For instance, in the area of patient support and self-management.
The complex and fragmented Belgian system made it imperative to disentangle elements at macro level first, to understand the variation in implementation at meso and micro level.
The Cambodian roadmap was developed towards a national strategic plan aiming to address two main issues: the low performance of the current type 2 diabetes (T2D) and hypertension (HTN) interventions for primary healthcare; and the low proportion of people with T2D and/or HTN who know their status. Top-down decisions could facilitate integrated care scale-up, including financing mechanisms.
The Slovenian roadmap revolves around pilot studies that explored various models of task-shifting, namely: m-health intervention to support and empower vulnerable patients; group-education program by patients as peer-educators; community-based healthy lifestyle intervention; and intra-team collaboration to improve organisation of the multidisciplinary team of primary care providers.
The Belgium roadmap focussed on a networking approach (i.e. iterative engagement and dialogue to enable change) to facilitate dialogue, synergies, and collaboration between different stakeholders. Key scale-up strategies include better chronic care organization in primary care practices; supporting efforts to connect different data sources; development of a dashboard for monitoring and evaluation of key indicators; and assessment of facility-based health-economic implications of integrated care.
Given the impact evaluation challenges, we evaluated SCUBY’s impact (SO3) based on the domains below:
1.Primary research-related impact - generation of new knowledge, knowledge dissemination, capacity building, training, leadership, and the development of research networks
2.Influence on policy making - interactions between academics and policy makers, which may influence policy-making development and implementation
3.Health and health systems impact - evidence-based practice, quality of care and service delivery, cost containment and effectiveness, resource allocation and workforce
4.Health-related and societal impact – cannot be assessed currently
5.Broader economic impact – cannot be assessed currently
For SO4, we identified challenges to macro-level barriers to scaling-up the different integrated care elements; roadmap development and implementation; and impact evaluation.
These are all detailed in the D6.2 Impact evaluation report.
