When and how far to take an integrated approach?

by admin on December 9, 2011

Blog post by Alice Hartley

“Today we can see that in the poorest places, only integrated approaches—those that take into account water, sanitation, economic opportunity, education and infrastructure along with health—sustainably and adequately address public health needs…Figuring out how to bring the complex matrix of development together requires systems knowledge, financing, and superb management.”

 –Josh Ruxin, “Doctors Without Orders”, Democracyjournal.org (summer 2008)

As we’ve seen in class, “free” health services often aren’t really free. Receiving treatment often entails patients losing days of work, paying to get themselves to a clinic or hospital, and incurring other indirect costs of treatment. Some organizations, such as the Aravind Eye Care System, recognize this.  They not only provide free eye surgery but also free local transportation, food, and accommodation. This patient-centric approach considers the full chain of events required to deliver on the promise of its free services.

So you wonder, are there limits to taking an integrated approach? When should a service or benefit be considered out of scope for a health organization? Does it depend on who’s funding the organization, the organization’s stated mission, or is it a judgment call to be made in the local context?

One of the organizations we studied, Smile Train, repairs cleft lips and palates with a relatively simple, high-impact surgical intervention. Its motivation for correcting this birth defect is not just cosmetic, however – it wants to enable children to return to school, daughters to get married, and adults to lead normal, economically productive lives. If its real goals, then, are economic and educational, would Smile Train turn down a donor that wanted to pay for patients’ school fees or add literacy training to its list of services? On the one hand, maybe Smile Train should consider partnerships that complement its intentionally single-issue focus; on the other, one of Smile Train’s secrets to delivering services at high volume has been avoiding “mission creep” into other areas of need.

An organization I know in Cambodia, the Angkor Hospital for Children (AHC) (www.fwab.org), resolves this question by working on several levels of intervention at once. The original hospital (founded in 1999 by a photographer with no medical background but a lot of friends – fascinating story) is the core, serving 300+ children a day. Two years after founding the hospital, AHC introduced a Capacity Building and Health Education Program, going “upstream” into communities to provide preventative care and education. Three years after that, the hospital established an official Medical Education Center focused on compounding the number of trained medical professionals in Cambodia – which had dipped as low as 45 doctors total in the 1990s. The AHC extended its services because it believes in a holistic approach to health care, and sees that improving the supply of medical workers and health practices at home will eventually relieve demand on its core service center, the hospital. It would be interesting to have been a fly on the boardroom wall as these expansions were weighed against the mission and philosophy of the AHC.

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