Periodic Reporting for period 3 - SCUBY (SCale Up an integrated care package for diaBetes and hYpertension for vulnerable people in Cambodia, Slovenia and Belgium)
Periodo di rendicontazione: 2022-01-01 al 2023-06-30
Global commitments have been made towards an integrated care approach which offers non-episodic and patient-centered care to address the rising burden of chronic diseases, particularly in LMICs. The SCUBY project aimed to provide solutions from implementation science through the development, adoption and evaluation of roadmaps on scale-up of integrated care for type 2 diabetes (T2D) and hypertension (HT) in three distinct contexts: a health system in development (Cambodia), centralized health system (Slovenia), and decentralized health system (Belgium). The project prioritised vulnerable populations.
The specific objectives were:
1.To analyse the organisational capacity to scale-up integrated care for HT and T2D in Belgium, Slovenia and Cambodia and to assess contextual barriers and facilitators to do so.
2.To develop and implement roadmaps for a national scale-up strategy in each country.
3.To evaluate the impact on health outcomes and efficiency of care.
4.To generate lessons across contexts on the scale-up strategies for integrated care for HT and T2D.
The specific objectives were:
1.To analyse the organisational capacity to scale-up integrated care for HT and T2D in Belgium, Slovenia and Cambodia and to assess contextual barriers and facilitators to do so.
2.To develop and implement roadmaps for a national scale-up strategy in each country.
3.To evaluate the impact on health outcomes and efficiency of care.
4.To generate lessons across contexts on the scale-up strategies for integrated care for HT and T2D.
For SO1, an in-depth situation analysis for each country was conducted using quantitative and qualitative methodologies.
An Integrated Care Package (ICP) Assessment Grid was developed measuring six integrated care elements (identification; treatment; health education; self-management support; structured collaboration; and care organization) using a 6-point Likert scale (from 0 - no implementation to 5 - full implementation). We also developed cascades of T2D and HT care (CoC) for each country, quantified the losses through the care continuum, and connected the cascades to the level of implementation of the six ICP grid elements. Focus group discussions were conducted to get a deeper understanding of the results.
The three countries adopted different study methods and achieved different levels of progress of the health financing aspects. A more in-depth assessment was done in Cambodia. Demand- and supply-side costing data were collected for Slovenia. The costing exercise was not accomplished in Belgium.
To note, data acquisition challenges were encountered in all implementing sites as from baseline; these are described in the D6.2 Impact evaluation report.
Based on the broad contextual understanding, we initiated the development of roadmaps to scale up integrated care and the three countries launched formal and informal policy dialogues with stakeholders to improve and/or facilitate scale-up (SO2). The roadmap is identified as the scale-up intervention and the policy dialogue as the main implementation strategy. We convened policy dialogues through multiple stakeholder meetings for co-creation and further engagement and collaboration throughout the project’s lifetime. These participatory processes bring together evidence (the scale-up roadmap). The roadmap documents were adapted over time and we expect that each roadmap will evolve in different ways.
For SO3/Phase 3, deviations from the original plan occurred, mainly due to the effects of the COVID-19 on health systems priorities in the project; these adversely affected roadmap implementation and collection of post-intervention data for the evaluation of the impact of the scale-up. Detailed information is provided in D6.2 Impact evaluation report.
SO4 includes the development of dissemination materials, publications, etc; a Community of Practice (https://www.thecollectivity.org/en/communities/22(si apre in una nuova finestra)) was convened and a SCUBY website (https://www.scuby.eu(si apre in una nuova finestra)) created.
An Integrated Care Package (ICP) Assessment Grid was developed measuring six integrated care elements (identification; treatment; health education; self-management support; structured collaboration; and care organization) using a 6-point Likert scale (from 0 - no implementation to 5 - full implementation). We also developed cascades of T2D and HT care (CoC) for each country, quantified the losses through the care continuum, and connected the cascades to the level of implementation of the six ICP grid elements. Focus group discussions were conducted to get a deeper understanding of the results.
The three countries adopted different study methods and achieved different levels of progress of the health financing aspects. A more in-depth assessment was done in Cambodia. Demand- and supply-side costing data were collected for Slovenia. The costing exercise was not accomplished in Belgium.
To note, data acquisition challenges were encountered in all implementing sites as from baseline; these are described in the D6.2 Impact evaluation report.
Based on the broad contextual understanding, we initiated the development of roadmaps to scale up integrated care and the three countries launched formal and informal policy dialogues with stakeholders to improve and/or facilitate scale-up (SO2). The roadmap is identified as the scale-up intervention and the policy dialogue as the main implementation strategy. We convened policy dialogues through multiple stakeholder meetings for co-creation and further engagement and collaboration throughout the project’s lifetime. These participatory processes bring together evidence (the scale-up roadmap). The roadmap documents were adapted over time and we expect that each roadmap will evolve in different ways.
For SO3/Phase 3, deviations from the original plan occurred, mainly due to the effects of the COVID-19 on health systems priorities in the project; these adversely affected roadmap implementation and collection of post-intervention data for the evaluation of the impact of the scale-up. Detailed information is provided in D6.2 Impact evaluation report.
SO4 includes the development of dissemination materials, publications, etc; a Community of Practice (https://www.thecollectivity.org/en/communities/22(si apre in una nuova finestra)) was convened and a SCUBY website (https://www.scuby.eu(si apre in una nuova finestra)) created.
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.
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.