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Roberta Heale 1 ,
Alison Twycross 2
1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
2 School of Health and Social Care , London South Bank University , London , UK
Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6 ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

Gustafsson J
Calanzaro M
Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Unit 5 Health and Social Care Nusrat and Maria Case Studies

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The case study approach

Sarah Crowe 1 ,
Kathrin Cresswell 2 ,
Ann Robertson 2 ,
Guro Huby 3 ,
Anthony Avery 1 &
Aziz Sheikh 2

BMC Medical Research Methodology volume 11 , Article number: 100 ( 2011 ) Cite this article

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The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Peer Review reports

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables 2 , 3 and 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 – 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 – 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8 )[ 8 , 18 – 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9 )[ 8 ].

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

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Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

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Sarah Crowe & Anthony Avery

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AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

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Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

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DOI : https://doi.org/10.1186/1471-2288-11-100

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Integrated care in practice: a case study of health and social care for adults considered to be at high risk of hospital admission

Integrated care is pursued globally as a strategy to manage health and social care resources more effectively. It offers the promise of meeting increasingly complex needs, particularly those of aging populations, in a person-centred, co-ordinated way that addresses fragmentation and improves quality.

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Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country.

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Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods.

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Johnson, P. & Gordon, R. , 2013. Hauwa Ibrahim: What Route to Change? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case explores Nigerian attorney Hauwa Ibrahim’s defense of a woman charged with adultery by Islamic Shariah law. One of Nigeria’s first female lawyers, Ibrahim develops a strategy to defend a young married woman, Amina Lawal, against adultery charges that could potentially, if the court judged against her, result in her death. While many Western non-governmental organizations and advocacy groups viewed Lawal’s case as an instance of human rights abuse and called for an abolition of the Shariah-imposed punishment, Ibrahim instead chose to see an opportunity for change within a system that many – especially cultural outsiders – viewed as oppressive. Ibrahim challenged the dominant paradigm by working within it to create change that would eventually reverberate beyond one woman’s case. Willing to start with a framework that saw long-term opportunity and possibility, Ibrahim developed a very measured change approach and theory framed in seven specific principles. Additionally, Ibrahim’s example of challenging her own internal paradigms while also insisting that others do the same invites students to examine their own internal systems and paradigms.

Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), learned on April 7, 2020 that the City of Boston needed BHCHP to design and staff in 48 hours one half of Boston Hope, a 1,000-bed field hospital for patients infected with COVID-19. The mysterious new coronavirus spreading around the world was now running rampant within BHCHP's highly vulnerable patient population: people experiencing homelessness in Boston. A nonprofit community health center, BHCHP for 35 years had been the primary care provider for Boston's homeless community. Over the preceding month, BHCHP's nine-person incident command team, spearheaded by Gaeta and CEO Barry Bock, had spent long hours reorganizing the program. (See Boston Health Care for the Homeless (A): Preparing for the COVID-19 Pandemic.) BHCHP leaders now confronted the most urgent challenge of their long medical careers. Without previous experience in large-scale disaster medicine, Gaeta and her colleagues had in short order to design and implement a disaster medicine model for COVID-19 that served the unique needs of people experiencing homelessness.

This case study recounts the decisive actions BHCHP leaders took to uncover unexpectedly widespread COVID-19 infection among Boston's homeless community in early April 2020. It details how they overcame their exhaustion to quickly design, staff, and operate the newly erected Boston Hope field hospital for the city's homeless COVID-19 patients. It then shows how they adjusted their disaster medicine model when faced with on-the-ground realities at Boston Hope regarding patients' psychological needs, limited English capabilities, substance use disorders, staff stress and burnout, and other issues.

Weinberger, E. , 2017. Coloring the Narrative: How to Use Storytelling to Create Social Change in Skin Tone Ideals , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Many millions of people around the world experience the pervasive, and often painful, societal messages of colorism, where lighter skin tones are asserted to be more attractive and to reflect greater affluence, power, education, and social status. Even in places where the destructive effects of colorism are fairly well understood, far less is known about the problem of skin-lightening (really, it’s “skin bleaching”) creams and lotions, and the health risks that consumers assume with these products. In this teaching case, the protagonists are two women who have recently immigrated to the United States from Nigeria and Thailand, both with a life-time of experience with these products like many of the women of their home countries. As the story unfolds, they struggle along with the rest of the characters to copy with the push and pull of community norms vs. commercial influences and the challenge of promoting community health in the face of many societal and corporate obstacles. How can the deeply ingrained messages of colorism be effectively confronted and transformed to advance social change without alienating the community members we may most want to reach? Teaching note and supplemental slides available for faculty/instructors .

This module will present two unfolding case studies based on real-world, actual events. The cases will require participants to review videos embedded into three modules and a summary module: Introduction to Concepts of Social Determinant of Health and Seeking Racial Equity Case Study on Health and Healthcare Context - Greensboro Health Disparities Collaborative (GHDC) Case Study on Social and Community Context - Renaissance Community Cooperative (RCC) Summary (Optional)

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Quelch, J.A. & Rodriguez, M.L. , 2015. Philips Healthcare: Marketing the HealthSuite Digital Platform , Harvard Business Publishing. Available from Harvard Business Publishing Abstract In June 2014, leading healthcare and consumer technology company, Royal Philips ("Philips"), announced its HealthSuite Digital Platform to house healthcare data and enable applications used by physicians and patients. Philips had strong equity in the healthcare technology space, due to its extensive portfolio of medical devices and related software sold primarily to hospitals. Philips designed the first two apps for the platform (eCareCoordinator and eCareCompanion) in-house, but it planned to open it up to third-party developers who would create an array of health-focused apps. Healthcare had long lagged behind other industries in adoption of technology as well as patient-relationship management. However, many health players had recently increased investment in new infrastructure and data analytics. Would the new Philips HealthSuite Digital Platform find success in the rapidly evolving industry?

Datar, S.M., Cyr, L. & Bowler, C.N. , 2018. Innovation at Insigne Health , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Insigne Health is a for-profit, integrated health insurer/health care provider whose leadership believes that by shifting members' focus from "sickness" to "well-being" it could increase the overall health of its insured population and decrease the resources it spends each year on delivering care. The case puts students in the role of design researcher charged with understanding the member segment about which Insigne Health leadership is most concerned: The "silent middle." This cohort represents 70% of membership and is "neither sick nor well." Without changes in a range of behaviors, these members may be quietly developing conditions that will evolve into costly chronic diseases. From interviews included in the case, students uncover insights into member behavior and, based on these insights, generate and develop concepts to help members change behaviors and lead healthier lives.

Gordon, R. & Moon, S. , 2014. Haiti in the Time of Cholera , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case examines the United Nations' reactions to the cholera epidemic in Haiti and illuminates contemporary gaps in global governance. In January, 2010, an earthquake devastated Haiti, the poorest country in the Western Hemisphere. The public health community anticipated Haiti to be at risk for many health threats, but did not consider a cholera outbreak a likely possibility. However, in October of that year, the first case of cholera in more than 100 years was reported, sparking a cholera epidemic in Haiti. Scientific evidence later linked the original source of the cholera to poor sanitation management practices at a United Nations (UN) peacekeepers camp run by Nepal. However, the UN refused to acknowledge any responsibility for causing the cholera outbreak. Readers of this case consider the role of global governance and accountability, especially in an environment with a weak nation state.

This multimedia module includes three clinical case videos demonstrating a variety of geriatric patient circumstances. Participants will view each case with attention to the medical care provided, as well as the impact of the social determinants of health (SDOH) in each scenario. The provider, in each case, models how to integrate the SDOH into the care plan to optimize the patient’s health and functionality.

Facilitators who utilize this module will develop panels from local community and state agencies to follow each case. The panels serve to deepen the learning experience through discussion and linking the participants to local experts. This strengthens the participant’s ability to apply lessons learned from this module in the clinical community contexts they serve.

The learning objectives for this module are directly related to Healthy People 2020 with the core SDOH categories including: economic stability; social and community context; health and healthcare; neighborhood and built environment; and environmental conditions.

Quelch, J.A. & Rodriguez, M. , 2014. Vaxess Technologies, Inc , Harvard Business Publishing. Available from Harvard Business Publishing Abstract In February 2014, Michael Schrader, chief executive of Vaxess Technologies, Inc., was assessing the startup health care company's 2014 marketing plan. On December 31st, 2013, Vaxess had obtained an exclusive license to a series of patents for a silk protein technology that, when added to vaccines, reduced or removed the need for refrigeration between manufacturing and delivery to the end patient. Schrader and his colleagues had to decide on which vaccines to focus and whether and how to target the drug companies that manufactured the vaccines or the quasi-government organizations (such as UNICEF and PAHO) and nongovernment organizations (such as GAVI) that purchased large quantities of vaccines for the developing world.

Kane, N.M. & Madden, S.L. , 2013. Implementing a Patient-Centered Medical Home on Mount Desert Island , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case presents organizational challenges facing a physician champion of the Patient-Centered Medical Home (PCMH). Dr. Julian Kuffler, working with his employer, the Mount Desert Island Hospital System (MDI), hoped to persuade the primary care physicians in the system to embrace the PCMH care model. Physician resistance was strongly opposed to some of the key principles of PCMH, such as managing the health of a defined population, standardizing chronic care management protocols, delegating patient care tasks to non-physician members of a care team, and to having strong physician leadership at the system level. At the same time, MDI was a small rural “critical access hospital” with declining admissions, predominantly outpatient-based revenues, and deteriorating finances. MDI leadership viewed high quality primary care to be essential for MDI to be able to attract the best health system partner with which it could affiliate to become part of a larger, more financially viable organization. MDI leadership also hoped to find a partner that could also support its participation in new population health arrangements such as accountable care organizations.

Weinberger, E. , 2014. Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract How does one learn to become an effective advocate? “Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry” tells the story of protagonist Joe Wendell, known as Wendell, an emergency room nurse and widower raising a teenage daughter in Franklin, a largely working class town in the fictional US state of Columbia. One day his daughter announces she would like to have breast implants. The distressing news prompts Wendell into new, unforeseen directions as he learns all he can about implants and surgery, the “beauty culture” permeating society especially in his community, and the psychological development of teenagers. Though relieved to find out that as long as she is a minor she cannot legally obtain the surgery without his consent (and, no doubt, without his cash), Wendell starts to believe that greater protections for teen girls in Columbia are needed. In this effort he is guided by the confident figure of Anna Pinto, director of a community center in an East Franklin neighborhood with a vibrant Brazilian-American community where cosmetic surgery, especially for girls and young women, is something she perceives to be a particular problem and has some ideas about how to address. Teaching note available for faculty/instructors .

Singer, S. , 2013. Surgical Safety Simulation Exercise , Harvard T.H. Chan School of Public Health. Abstract In this simulation exercise, students are given the opportunity to think critically about the role of motivation and organizational context in implementing a process innovation. Students work in teams of four to six people to develop recommendations for a hospital president on the best ways to implement a surgical safety checklist. Simulation available upon request from author .

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Journal of Integrated Care

ISSN : 1476-9018

Article publication date: 12 June 2023

Issue publication date: 10 August 2023

Canada's population is aging and there are concerns that the welfare system may not support the increased demands on it. Integrated health and social care (IHSC) produces positive health and system outcomes but it needs to be better understood within a Canadian context. The purpose of this collective case study of three IHSC initiatives in Alberta, Ontario and Nova Scotia was to determine the factors that support successful services integration among different healthcare and social services organizations serving older adults within a Canadian context.

Design/methodology/approach

This study used the Cheng and Catallo (2020) IHSC conceptual framework (CF) to guide the research. Primary data were based on key informant interviews of representatives from organizations that comprised each case and focus groups. A cross-case analysis was undertaken to determine common themes.

The cross-case analysis revealed that the three cases shared common integration and external influence factors based on the Cheng and Catallo (2020) CF. Some new factors were identified.

Originality/value

The study revealed that the Canadian context was important in influencing integration in the three cases and that there is a unique Canadian aspect to IHSC. The study offers up practical insights for government leaders and service administrators to improve IHSC for older adults. The study also identifies how the Cheng and Catallo (2020) IHSC CF can be enhanced and points to research opportunities to test the framework.

Integrated health and social care
Gerontology
Aging in place
Conceptual framework

Acknowledgements

Funding: This study is supported in part by funding from the Social Sciences and Humanities Research Council.

Cheng, S.M. and Catallo, C. (2023), "Collective case study: integrated health and social care for older adults within a Canadian context", Journal of Integrated Care , Vol. 31 No. 3, pp. 171-181. https://doi.org/10.1108/JICA-11-2022-0055

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Increasing awareness of bowel cancer symptoms among the Asian Community –NHS Hillingdon Clinical Commissioning Group (Formerly NHS Hillingdon)

This case study illustrates the benefits of collecting and using equality information to identify the needs of people with particular protected characteristics and to measure progress in responding to those needs over time.

NHS Hillingdon Public Health Team looked at the information available on cancer types and rates in the Borough in 2010. They found that:

Among cancers, bowel cancer accounted for a large proportion of cancer deaths;
More people under 75 were dying of cancer in the South of the Borough which has a high Asian population compared to in the North;
Cancer was a substantial contributor to inequality in death rates, particularly among women living in the most deprived 20 percent of the borough.

Cancer can often be successfully treated if detected early. For example, eight out of 10 cases of bowel cancer can be treated successfully if detected early .

Action taken

Based on the baseline data outlined above, the Public Health Team decided to launch an awareness campaign in the South of the Borough (Hayes and Harlington) which has a high Asian population.

The Public Health Team found that members of the Asian community had more limited awareness of the symptoms of bowel cancer, which was reducing the chances of early diagnosis with implications for survival rates. One of the reasons for this appeared to be that Asian people felt that cancer did not affect their family or their community (or was less likely to affect them).

In light of these findings, NHS Hillingdon focused their campaign on various actions to raise awareness of the symptoms of bowel cancer among the Asian community, particularly women. Those actions included:

Designing and distributing leaflets about bowel cancer in English and in relevant Asian languages;
Holding workshops, facilitated both in English and in other predominant languages. These were organised through existing local organisations e.g. women's groups or charities particularly targeting Asian communities or religious centres;
Displaying campaign posters on buses and in tube stations in the Borough;
Promoting messages by advertising on the Sunrise Radio Network - the UK's largest Asian radio network.

Surveys undertaken before and after the campaign revealed that awareness of the main symptoms of bowel cancer increased among people who had received information from the Public Health Team. Almost 80 percent of those who had seen or heard at least one element of the campaign could spontaneously recall at least one symptom, compared to less than 60 percent of those who had not been exposed to promotional material.

Advertising on the Sunrise Radio Network was found to be particularly successful in reaching Asian women.

Using equality information to reduce non-attendance at the Diabetic Eye Screening Programme - Royal Marsden NHS Foundation Trust

All people with diabetes are at risk of developing diabetic retinopathy. This is the most common cause of blindness in people of working age in the UK. There are usually no obvious symptoms until it is well advanced. Evidence shows that early detection and treatment can prevent sight loss. It is therefore very important that it is identified and treated as early as possible.

The Diabetic Eye Screening Programme (DESP) offers annual eye screening to people with diabetes. Data collected in 2011/2012[1] about patients who did not attend showed that the service had the highest non-attendance rate (21.2 percent) of all services delivered by Sutton and Merton community services.

Actions taken

A health equity audit was commissioned to look at equity of service provision, uptake and outcomes among patients referred to the DESP. The audit looked at whether there were differences between the non-attendance rates of people with particular protected characteristics, i.e. age, gender and ethnicity.

The audit concluded in late 2012. It showed that patients of working age were more likely to miss appointments compared with older age groups, and the highest non-attendance rate (40 percent) was found in the 22-31 age group.

To improve accessibility for patients of working age, the service has expanded its out-of-hours provision to include weekend clinics. It also offers patients the option to make and change their appointments by email so that busy patients no longer have to call during working hours to do this.

These initiatives have contributed to reducing the overall non-attendance rate for the DESP. It has gone from 21.2 percent in 2011/12 to 15 percent in 2012/13.

Such a reduction in the non-attendance rate represents a financial saving for the Royal Marsden[2]. In addition, given the important role of screening in the early detection of diabetic retinopathy, such initiatives should have a positive impact over time in preventing sight loss among patients of working age.

Additional work currently under way

The audit commissioned in 2012 also suggested that White and Asian females and African males had higher non-attendance rates when compared with other ethnicities. However, it cautioned against drawing conclusions due to the quality of the data available.

As a result, the service has amended the data collection process for primary care providers. This will provide a more complete ethnicity profile for the population in future and will be used to re-audit service uptake in 2014/15.

[1] For the Royal Marsden Patient and Membership Equality Profile report 2011/2012

[2] According to the Dr Foster Hospital Guide 2012, 5.8 million outpatient appointments were missed by patients in 2011/2012, representing a loss of potential revenue to the NHS of £585 million. Reducing non-attendance rates not only represents a financial saving for the NHS, it is also a way to reduce waiting times and to improve efficiency.

Supporting job applications from disabled people: improving confidence and work experience for disabled people - Frimley Park Hospital

In its employment equality compliance report for 2010/2011, the Frimley Park Hospital NHS Foundation Trust (the Trust) noted that it had received fewer job applications from disabled people than might be expected, given that eight percent of the population in its catchment area is estimated to have a disability.

Although disability is generally underreported among applicants in the job market, the Trust felt that a specific commitment was needed in order to encourage more disabled people to apply for jobs at the Trust. Mindful of the specific duties (under the Public Sector Equality Duty), the hospital defined the following objective to fulfil this aim:

Work with organisations such as the Shaw Trust to place disabled people with the aim of developing skills and confidence to support long-term employment prospects. This includes provision of support for applying for permanent posts within the organisation.

In 2012/2013, the hospital contacted the Shaw Trust to ask for curriculum vitae of disabled people who were looking for work placements. The Shaw Trust put forward three curriculum vitae and the hospital identified placements that would best suit the skills of these individuals. Assistance with job applications/interviews was given at the end of the placements so that the three individuals could apply for temporary and permanent positions within the Trust.

In 2012/13, the Trust reported the following progress: out of the three disabled people appointed through Shaw Trust on work placements, two have now been appointed as temporary staff, and one to a permanent post.

The work placements at the hospital made a significant difference to the lives of those involved. In particular, it has enabled participants to gain skills and confidence to apply for jobs afterwards. One participant stated that it has enabled him to demonstrate his skills in a real workplace which gave him the confidence to apply for a permanent post in the Trust. 'At the interview, I could talk about real work skills I had developed in my placement, something I had previously been unable to do'.

The hospital is still working with the Shaw Trust to continue providing more disabled people with potential job opportunities in the coming years.

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Int J Integr Care
v.21(4); Oct-Dec 2021

Integrated Health and Social Care in England: Ten Years On

Robin miller.

1 University of Birmingham, UK

Helen Dickinson

2 University of New South Wales, Australia

Introduction:

As part of major policy reforms begun in 2010, England introduced a wave of initiatives to encourage more integrated care between health and social care. These built on previous attempts which sought to achieve similar objectives through a focus on better partnership working. This article provides an overview and critical commentary on integrated care policy in England from 2010–2020 based on reviews by regulators, parliamentary committees and the national audit office.

Overview of Policy:

Integrated care became a priority through the work of the Future Forum, a group of leading stakeholders established due to concerns about greater competition in public health care. This led to a public statement of shared commitment to integrated care by national health and social care bodies. Early mechanisms included a pooled fund to achieve nationally set objectives, the creation of local authority led partnership boards, and high profile innovation programmes. Later in the 2010’s, new health led partnerships became more dominant vehicles to achieve integrated care at regional level.

Impact of Policy:

Despite progress within a few local areas, and reduction in delayed discharges from hospital the overall picture from national reviews was that expected improvements were not achieved. Emergency admissions to hospital continued to grow, patients within primary care reported being less involved in their care, and health inequalities worsened. The initial response to COVID-19 was health-centric contributing to outbreaks in care homes and inadequate supplies of protective personal equipment. The ability of leaders to look beyond their organisations’ interests was reported as vital for local progress. National government performance frameworks discouraged system based working and chronic underfunding of social care led to major capacity and workforce challenges.

Conclusion:

The experience of England suggests that greatest progress is made when integrated care focusses on tangible issues and when there is a clear understanding of how success will be measured. Even with considerable investment and intent progress should be expected to be slow and difficult. Layering of numerous policy initiatives provides confusion and can distract from the important work of relationship building. And ultimately, integrated care cannot by itself address major inadequacies in the underlying resources and structural inequalities.

Introduction

A decade ago we published a paper within this journal [ 1 ] exploring partnership working between English health and social care organisations, summarising the key approaches adopted and whether this had resulted in positive impacts [either for those delivering care or for people receiving it]. In this paper we explore the experience of the past decade following this initial paper to explore whether progress has been made and what this tells us about collaborative working in health and social care settings. As such, this paper provides insights for an audience interested in the specific English context, but also generates lessons about how to drive joined-up working and the pitfalls to avoid that are relevant for broader international learning of integrated care. It also starts to explore how key concepts and policy agendas may evolve over time in response to significant national and international challenges such as the financial crisis of 2008 or COVID-19 and how much continuity there can be, even with governments of very different political persuasions in office. To understand policy aspirations and the progress achieved, we draw on reports by relevant governmental bodies. This includes reviews by the regulator of health and social care (Care Quality Commission), the independent spending watchdog (National Audit Office), and scrutiny committees within parliament (Committee of Public Accounts and Health and Social Care Committee). These bodies draw on a range of sources including directly gathering the views of people with lived experience of health and care services and/or engaging with their representative bodies. The authors are academics who have undertaken independent research of integrated care policy reforms in England over two decades.

Partnership working in health and social care

In exploring whether we have seen significant progress over the past decade we first need to revisit the context as it was in 2010. Health care in England has traditionally been coordinated and delivered through local planning and provider organisations which are part of the NHS. Whilst local NHS bodies have a degree of autonomy they have ultimately been accountable to the national government. Social care has been the responsibility of local authorities which have their own democratically elected governance structures. Local authorities follow national policy but have more autonomy than the NHS to decide on how these are implemented and how available funding is deployed. As we outlined at that time, the need for joint working across health and other agencies had been recognised for as long as the UK welfare state had been around. From the mid-1970s until the late 1990s there had been a range of consultative and planning committees established to encourage joint working in addition to a statutory duty for health and local government to collaborate. From the late 1990s, however, we saw a step change in the policy arena as partnerships emerged as a key priority area. A range of different organisational forms such as Care Trusts [ 2 ] and Children’s Trusts [ 3 ] were initiated alongside various changes to legal powers and policy exhortations [ 4 ]. These organisations were responsible for the planning and purchasing of services [i.e. commissioning in English terminology] and/or the delivery of community services. Over this period, the case was firmly made that collaboration was a necessity between health and social care. Indeed, this agenda was so firmly pressed that arguably it became heretical to even challenge the idea that partnerships were needed [ 5 ]. As we stated in 2011, ‘it has become increasingly clear that people do not live their lives according to the categories created in our welfare systems – and some form of joint working is essential if we are to find meaningful ways of joining up services in order to meet complex needs more fully’ [ 1: pg. 7 ].

Between 1997 to 2010, New Labour exhorted, compelled and incentivised agencies to work in partnership through a variety of means. For the most part, the governments of this period were not prescriptive about the form health and social care partnerships should take and seemingly allowed a level of local discretion in terms of how agencies, organisations and individuals would work together. National government focused on creating a context that was receptive to partnership working, promoting a series of different organisational structures that local areas could explore if they felt that they were right for them, and removing legislative boundaries to closer joint working. Yet, this focus on the macro level may have come at the detriment of the local level, where the actual work of collaboration is done [ 6 ]. As we argued in 2011, successive English governments had been unduly focused on the ‘structural’ elements of partnership working, which failed to acknowledge the reality of the ways that organisations and professionals develop relationships and trust in order to be able to work together. Joint working is about more than simply the removal of organisational and legislative boundaries, and the continual reorganisation of health and social care agencies continued to hamper attempts of local organisations in working together. It is perhaps unsurprising that a number of different studies remained skeptical as to whether partnerships had proved able to deliver significant outcomes [ 7 , 8 , 9 , 10 ]. However, as a caveat to this statement, a number of evaluators noted that the research evidence is not replete with rigorous studies of the outcomes of partnership working and that the challenges in undertaking this kind of research are plentiful [ 11 , 12 ].

What happened next?

As summarised above and in our original article [ 1 ], between 1997 and 2010 successive Labour governments placed significant emphasis on partnership working through a series of policy reforms. This period also saw substantial increases in health and social care funding over a sustained period, albeit the worldwide economic crisis of 2007–08 made future increases difficult for any government. In 2010, Labour lost the general election and a new government was formed by a Conservative-Liberal Democrat Coalition (2010–15). Within this government the Conservatives were particularly committed to a policy of austerity that resulted in reductions in public service expenditure. In 2015, the Coalition was replaced by a standalone Conservative government, which remains in charge at the time of writing (albeit with a series of different leaders over time). Below we set out the policy context with respect to the key issues relating to joined-up working in terms of three phases (2010–15, 2015–20 and the response to COVID-19). This is a necessarily brief account, but more detail can be found in [ 13 , 14 , 15 ].

Integrated care under the Coalition (2010–15)

Initially, there was little mention of joint working under the Coalition government. Their reforms were focused on increasing market forces in the NHS and putting oversight of local markets in the hands of general practitioners through Clinical Commissioning Groups. However, this became a specific policy priority after being taken up by the NHS Future Forum [a group of health and social care leaders and other stakeholders set up to review the government’s 2012 health reforms, established after a significant backlash to a perceived focus on competition over collaboration]. Whereas the previous government had used terms such as ‘partnership working’ and ‘joined-up solutions to joined-up problems’, the Future Forum and the Coalition tended to talk about ‘integrated care’ (sometimes referring to vertical integration between hospitals and community, and sometimes seeming to refer to horizontal integration between health and social services). This culminated in the publication of a ‘shared commitment’ to integrated care by all of the key national governmental and independent bodies for health and social care [ 16 ]. This was focused around the definition of person centred and coordinated care that was developed by the charity National Voices for this new National Collaboration: “I can plan my care with people who work together to understand me and my carer[s], allowing me control, and bringing together services to achieve the outcomes important to me.” [ 17: p. 3 ].

While the notion of ‘integrated care’ was widely promoted, there felt a potential disconnect between the senior health and social care stakeholders who had genuinely championed it, and a government looking for new language and approaches to salvage its controversial health reforms. As part of these changes, public health responsibility [and associated staffing and funding] for improving the health of the local population passed from the NHS to local government. This included providing information and advice on health improvement, supporting people to adopt healthier lifestyles and researching health inequalities. Other public health responsibilities such as protecting the public from major hazards and responding to public health emergencies passed to a new national body (Public Health England). A raft of supporting legislation and nationally led initiatives were introduced ( Table 1 ) These included the Better Care Fund to invest in joint priorities [with initial flexibility being reduced over time and becoming more focused on core NHS priorities such as tackling delayed hospital discharges]. The creation of Health and Wellbeing Boards within local government to bring together different partners to develop local strategies for health improvement (that seemingly had significant responsibilities and very little power to actually bring about change). Two pilot projects (the ‘Integrated Care Pioneers’ and ‘Vanguard’ sites), set up by slightly different parts of government to test new ways of joint working, arguably created a degree of overlap and confusion. Over time, there was a growing sense these were losing their initial locally-owned priorities and became dominated by targets relating to emergency hospital admissions and timely discharges from hospital.

Key policy initiatives and legislation relating in integrated health and social care in England between 2010 and 2014.


YEAR	TITLE	OVERVIEW

2012	Health & Social Care Act 2012	Established local health and wellbeing boards in each local authority area, with a duty to encourage the integrated commissioning of health and social care services. Required clinical commissioning groups to promote integration where this would improve quality or reduce inequalities.

2013	Integrated Care: Our Shared Commitment	The Department of Health and twelve national partners made a commitment for urgent and sustained action with an ambition to make joined-up and coordinated health and care the norm by 2018.

2013	Integrated Care and Support Pioneers	Twenty five local areas were selected to pilot new ways of working to improve the quality and cost-effectiveness of care for people whose needs are met from both NHS and local authority services.

2013	Better Care Fund	This national initiative required clinical commissioning groups and local authorities to pool a minimum of £3.8 billion to promote integrated working, overseen by local health and wellbeing boards

2014	Care Act 2014	Required local authorities to promote integration where this would promote wellbeing, improve quality, or prevent care needs from developing

2014	Five Year Forward View	Called for a ‘radical upgrade’ in prevention and public health; models of care which shift care from hospitals to settings closer to people’s homes. Introduced seven new models of care based around the Five Year Forward View to be piloted at 50 ‘vanguard’ sites

These various different initiatives proved unable to overcome the pressures and tensions created by austerity and by the Coalition’s reorganisation of the NHS (abolishing Strategic Health Authorities, who had a regional overview of the system, replacing more managerially-led Primary Care Trusts with more clinically-led Clinical Commissioning Groups, and creating a series of new national bodies). In effect, the impression was of a series of attempts to join back together relationships and accountability mechanisms that had been swept away, and to replace functions that turned out to be essential after they were abolished.

Integrated care under the Conservatives (2015-)

The Conservative governments between 2015 – 2020 sought not to reverse the fundamental issues of fragmentation within the health reforms but rather to introduce a series of NHS developments to recreate some of the governance and accountability mechanisms needed to help the health and social care system work together more effectively ( Table 2 ). At the regional level, this included the creation of Sustainability and Transformation Plans (STPs) across 44 different areas of England, in an attempt to bring key partners together to work on system-wide issues. These were NHS bodies which had no legal standing and for whom accountability was unclear other than being required to submit their plans for approval by national bodies. STP’s varied significantly in terms of the extent that individual partners are genuinely committed to the broader partnership, and some were accused of developing plans for potentially significant service change behind closed doors. Over time, the aspiration became to develop these into ‘Integrated Care Systems’ (ICS), a deeper collaboration to take more joint responsibility for local health care system resources and performance. Interestingly, these mechanisms lacked a statutory basis, making it difficult to know where power really resides, who to hold to account and how best to bring together a series of standalone health and social care organisations who are ultimately accountable to their own Boards or local councillors, rather than to each other. At the same time there was also been a trend towards greater economies of scale, with a number of mergers taking place between local hospital, community health and mental health providers. While policy remained based on an ongoing purchasing-provider split, the reality was that significant power lay with large acute providers, who seemed increasingly dominant within their local health economies. Within general practice, General Practitioners were encouraged to form new Primary Care Networks based on local communities of around 30,000 to 50,000 people, combining local care with the economies of scale that come from multiple practices working together.

Key policy initiatives and legislation relating in integrated health and social care in England between 2015 and 2020.


YEAR	TITLE	OVERVIEW

2015	Spending Review and Autumn Statement 2015:	Introduced a commitment to integrate health and social care services across England by 2020 and required local areas to submit plans by April 2017 demonstrating how they would achieve this

2015	Sustainability and Transformation Plans	Local health bodies were required to draw up plans to improve services and finances over the five years to March 2021 around identified ‘footprints’. There was a subsequent shift in focus from the ‘Plan’ to the ‘Partnerships’

2018	Integrated care systems	Advanced forms of Sustainability and Transformation Partnerships in which the local NHS organisations are awarded greater autonomy over use of available funding and managing the quality of their health care services. National bodies only assure system level plans rather than those of individual organisations. Local areas applied for this status.

2019	NHS Long Term Plan	Committed to the development of Integrated Care Systems in every area of England by 2021.

2019	Primary Care Networks	Individual general practices can establish or join PCNs covering populations of between 30,000 to 50,000 to integrate primary care services around local communities and collaborate with other relevant agencies [including social care]

The response to COVID-19

As the effects of the COVID-19 pandemic began to spread around the world, this has intensified the need for public services such as health and social care to work together. At the local level this led to a series of very rapid and innovative bottom-up approaches, potentially overcoming years of tensions and barriers. In one locality, for example, there was joint work to tackle rising rates of domestic violence, action to reduce rough sleeping during the national ‘lockdown’, and work with supermarkets, banks, IT providers and the voluntary sector to make sure that families in need were fed, had access to emergency finance and had internet access for educational purposes [personal communication].

However, such activity often took place underneath the policy radar, and there were significant criticisms that national policy has prioritised urgent changes to the delivery of hospital services at the possible expense of others parts of the health and social care system. While a key priority was quite rightly been to reconfigure hospital services, expand intensive care and maintain as many other health services as possible, services such as care homes or supported housing felt almost entirely neglected, struggling with access to personal protective equipment, with staffing, with funding and with devastating mortality rates [ 18 ]. Even national attempts to say thank you to public sector workers helping to get society safe seemed to priortise NHS staff, with care workers feeling marginalised and under-appreciated. None of this has been caused by the pandemic as such but rather highlighted the fragmentation and vulnerability of adult social care to an even greater extent than before.

During this period the government announced that Public Health England, only created during the Conservative health reforms of 2012, would be replaced by a new National Institute for Health Protection, amidst fears that Ministers were seeking to pass responsibilities for national failures to an arms-length body. There were also been significant debates around the respective roles of the Secretary of State for Health and Social Care and NHS England [the body created in 2012 to give the NHS a degree of independence from day-to-day government intervention in the health service].

What difference have these policies made?

The overall objectives of these various integration strategies was articulated in a cross-departmental policy statement [ 16 ]. This reflected the widely adopted ‘triple aims’ of integrated care – “individual experience of integrated care and support that is personalized and coordinated, shift away from over-reliance on acute care towards focus on primary and community care, and population based public health, preventative and early intervention strategies” [p. 13]. Given the prioritisation of integration and the considerable financial investment connected to its implementation, there was a series of reviews by Parliamentary committees and national scrutiny bodies to determine the difference this has made. These suggested a degree of progress has been made towards the over-reliance on acute care. For example, the National Audit Office [ 19 ] reported the Better Care Fund resulted in a reduction in permanent admissions of older people to care homes, and a greater proportion of older people remained at home following discharge from hospital. The Vanguards in particular were seen to be successful in reducing growth of emergency admissions to hospital [ 20 ] and there was also a steady reduction in the number of hospital beds occupied by people who were fit to be discharged but were experiencing a ‘delayed transfer of care’ between 2017 and 2019 [ 21 ].

Overall it is clear that integration of care in England has not achieved the wide variety of different aims and objectives that have been aspired to. For example, patients report that since 2012 they are less involved in making decisions regarding their primary care services and receive less support to manage their own care [ 22 ]. National data suggests emergency admissions have continued to grow and many of these are avoidable. For example, in 2016–2017 NHS England estimated that 24% were avoidable [ 23 ]. Moreover, there has been a general slowing in the increase of life expectancy with the greatest impact in areas of high deprivation. Female life expectancy has declined in the more deprived 10 per cent of neighborhoods and regional inequalities in life expectancy have also grown. In 2018 there were 69 percent more children within homeless families in temporary accommodation in 2018 than in 2010, child poverty rates have returned in the same time period to pre-2010 levels [ 24 ]. Care for particular ‘seldom heard’ groups has also been of significant concern. For example, there have been several national policy initiatives during the decade to reduce the number and length of stay of people with a learning disability and complex needs who are detained for extended periods in assessment and treatment facilities [e.g. 25 , 26 ]. Despite these, and the connected investment in partnership infrastructure, practice developments and performance monitoring, in 2020, 2,095 people were being cared for in such facilities and over 60% were subject to stays of over 2 years [ 27 ]. The “undignified and inhumane care” that many received could have been avoided through better coordination and community based support [ 28: p. 3 ].

A major issue within all forms of integrated care is the high level of variation across England. A minority of areas do appear to have made substantial progress in relation to better joint working between health and social care (for example Frimley, Nottinghamshire and Greater Manchester). However the majority have not made such bold progress and some have achieved little improvement in their ability to better collaborate across health and social care. As a consequence, cross-bench committees of Members of Parliament have questioned the government’s ability to achieve consistent integration of care [ 20 , 29 , 30 ], as have national scrutiny bodies [e.g. 23 , 31 ]:

“There are examples across England where integrated working has been successfully applied. But it is a long way from being in place everywhere, with a range of longstanding legal, structural and cultural barriers hindering the pace and scale at which change can happen.” [ 20: p. 3 ] “The Department’s expectations of the rate of progress of integration are over-optimistic. Local areas that have achieved more coordinated care for patients from closer working between social care and NHS organisations have been doing so for up to 20 years.” [ 19: p. 18 ]

Local factors have undoubtedly had a role in this lack of consistent improvement. While some leaders are able to work beyond their organisational interests in order to respond to the needs of local communities, there are also many examples where this is not the case. Social care and the wider voluntary sector are still often excluded from strategic discussions and the pressure of responding to COVID-19 has led to greater tension [ 31 ]. The factors that have enabled better local collaboration in England are not new – a common vision focused on the local population, joint planning and funding arrangements, a supported and resourced workforce, and shared governance and communication processes [ 32 ]. Leadership continues to be highlighted as a vital enabler or major barrier [ 19 ]. Put simply, where senior leaders are willing to engage, understand and respond to those from other sectors there is the opportunity for progress. Where this is not the case, however, fragmentation remains and opportunities to explore new flexibilities are not exploited [ 32 ]. Once again, the importance of trust between individuals and the necessity of forums and meetings in which constructive relationships between health and social care organisations can be fostered has been highlighted.

Alongside local factors there remain numerous other barriers that restrict integration. While pooling of funds is possible, the legislative framework makes this a complex and arduous task due to a requirement on individual organisations to safeguard their own financial position [ 30 ]. There are different regulations regarding Value Added Tax (a general tax on goods and services) for NHS organisations, independent providers and local authorities which can result in unaffordable tax bills being levied on new organisational partnerships [ 30 ]. Major problems with transferring staff between sectors due to pension differences also remain [ 30 ]. Similar challenges relate to siloed regulatory regimes and to STPs and ICSs not having the legislative status of ‘statutory bodies’. They do not have formal legal authority, and runs the risk of undermining transparency and accountability [ 30 ]. The discrepancies between health and social care present numerous difficulties. These include: the financial insecurity of social care providers and thereby sustainability of the market; enormous challenges concerning the recruitment and retention of social care staff; considerable differences in terms of pay and the status of the health and social care workforces; and, the sheer complexity of social care funding. National bodies have also been seen to have most interest in those areas making greatest progress to the practical and financial detriment of areas finding integration harder to achieve [ 29 ]. Finally, unprecedented cuts to local authorities and related public bodies has led to a decline in spending on social determinants of health with more deprived areas and populations being disproportionally affected [ 21 ].

The continued fragmentation between health and social care was perhaps most acutely demonstrated during the early stages COVID 19 pandemic. The National Audit Office [ 37 ] reported that responding to the emerging situation was “undoubtedly made harder because of historic and unaddressed differences and divisions between the two sectors” [p4]. It appeared that the focus of government was on ensuring that hospitals had sufficient capacity with insufficient attention paid to the risks of the virus spreading to residents and staff within care homes. For examples, there was an initial lack of requirement for all patients discharged from hospital to have a COVID test and an expectation that care homes must fill their capacity and admit patients with COVID 19. Testing was subsequently introduced on discharge due to numerous outbreaks within care homes. Similarly, whilst there were problems in relation to clarity of guidance and practical access to personal protective equipment in both sectors, social care providers raised concerns that the advice was tailored to health care settings and that they had even greater difficulty in obtaining sufficient supplies [ 38 ]. It is worth noting that the major discrepancies between health and social care relate to decisions taken at the national level. Within local areas, there were numerous examples of constructive collaboration with reports that the scale and urgency of the response resulted in the “breaking down of longstanding boundaries” between health and social care [ 39 p5].

So what might we take from the last few decades of England’s experience of integrated care? In one sense this is a success story. It is clear that integrated care matters. Under governments of different hues, although the terminology has changed, integrated care has remained a key area of policy focus and of significant local activity and commitment. For all of the well-rehearsed difficulties associated with integrating care, health and social care professionals know that they need to work together to deal with many of the pressing challenges that their organisations and communities face. While progress can be slow and incredibly frustrating, professionals, local services and policy makers all want to make integration work – and what was once something of a ‘bolt-on’ to traditional ways of working has now become part of the mainstream.

Despite these changes in emphasis and focus, the greatest progress has arguably been made when local areas have focused on specific tangible tasks or issues. To some extent this is not a new observation, with some of the authors noting this in relation to joint commissioning nearly a decade ago [ 33 ]. Where local aspirations for integrated care are broad and amorphous (e.g. ‘reduce health inequities’, ‘improve care’) there is greater room for this to be interpreted in multiple ways and this is less able to galvanize local action. Where specific locally-relevant aspirations are articulated that a range of partners are able to buy into or take ownership of, these have a greater chance of being achieved. Individuals and their organisations are more likely to put aside differences and be willing to take the risk of trusting each other when they can see tangible benefits. What this means is that integrated care initiatives need to be clear about what they are trying to achieve and for whom, design their approach with this in mind, and regularly measure their performance against these goals in order to be effective.

In other ways, however, the English experience is less of a success story. There is still too much of a tendency to see integration as somewhat of a prescription for all ills. As such there is a tendency to over-promise in terms of what can be delivered and this inevitably sets some initiatives up to fail. We need to have more realistic views of what can be achieved through integration and the amount of time that it takes to achieve this – particularly when setting up new initiatives (or even new organisations) from scratch. While we may see some early impacts around delayed transfers of care or emergency readmissions to hospitals, it might take longer to see significant impacts or to see broader changes (such as a reduction in health inequalities). If we expect too much of these integration arrangements, we are setting them up to fail. This can disengage staff and those using these services as they will lose trust in the promised made by those in more senior roles within partnerships.

One of the issues we have clearly seen is that a hyperactive policy context is not helpful to developing and sustaining joint activity. Over at least the last ten years, we have seen a layering of new policy on top of old policy and a number of pilots that have been established but not maintained for sufficiently long to have an influence on mainstream services. Just over a decade ago, Professor Kieran Walshe [ 34 ] described the continual reorganisation of the NHS as creating organisational ‘shanty towns’, where new entities were hastily constructed, knowing that they too would soon be swept away. The recent experience of integrated care again demonstrates that this kind of frenetic policy context is not helpful to creating and maintaining relationships or to building for the long-term. Rather than simply bolting on new policy reforms or new agencies we would argue we need to fundamentally change the underlying system if we are serious about making integrated care work.

Walter Leutz [ 35 ] famously set out his five laws of integration and his fourth point was that ‘you can’t integrate a square peg into a round hole’. This law is sometimes interpreted to mean that you cannot prescribe one approach to integration and all approaches need to be locally developed. The English experience demonstrates this to be true. But Leutz, in making this point, was also indicating that some systems are unable to be integrated because they simply do not fit together. We might argue that after more than two decades of significant effort to drive integration, any lack of further progress is unlikely to be simply due to a lack of will or effort. Instead, it is likely that there is a more fundamental issue at the core of this lack of widespread success. English health and social care services were simply not designed either as a system or with integration in mind. This issue has arguably become even clearer over the last decade as we have seen social care starved of funding. As a result, it remains the poor relation of the NHS. All too often policies badged as being about ‘integrated care’ default to health-related outcomes and to hospital care (which is the most powerful and best resourced part of the current system). Unless we see significant investment in social care and pay attention to the underlying funding of core services then it will remain difficult to drive integration much further and maintain progress on a long term basis.

As 2020 came to an end, Integrated Care Systems were confirmed to be the principal vehicle through which greater collaboration is to be achieved in the decade to follow. A consultation document set out proposals that would address a number of the concerns outlined above [ 36 ]. This includes giving Integrated Care Systems a stronger footing in legislation, aligning priorities through a common ‘triple aim’ duty on all NHS organisations, and developing a ‘single’ health care funding pot with local freedoms. All worthy developments, but the document is undeniably still NHS-centric with local authorities and the voluntary sector getting scant mention other than being noted as important partners to the NHS. Even less considered is how people and communities will be able to influence the work of these powerful new bodies. Casting our minds back to the beginning of the decade, this presents a contrasting image to the shared vision launched by the National Collaboration. More people-centric in tone, it suggested greater equality between health and social care, the NHS and local authorities, and the statutory and voluntary sectors. Instead, the image portrayed is that Integrated Care Systems are at their heart a health care concern. If this proves to be the case, then much of the good work from the 2010’s will be lost. This would be a travesty, particularly in light of the acceleration in collaboration between health and social care that was experienced by many local areas by the end of the first year of the COVID 19 response. The pandemic has left local authorities and therefore social care in an even worse financial position and the NHS has accumulated huge waiting lists for planned care procedures. There is therefore a significant danger that these sectors may retreat to focus on their own pressures. One must hope that other countries can still learn from what went well and that, in time, England will regain its vision for a more holistic and equitable health and social care system.

Acknowledgements

RM’s contribution was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Funding Statement

Dr Frances Cunningham, Honorary Fellow, Menzies School of Health Research, Australia.

Prof. dr. Mirella MN Minkman, CEO, Vilans, Netherlands.

Competing Interests

The authors have no competing interests to declare.

Open access
Published: 28 August 2024

International aid management in Afghanistan’s health sector from the perspective of national and international managers

Noorullah Rashed 1 , 2 ,
Hamidreza Shabanikiya 1 , 4 ,
Leili Alizamani 1 ,
Jamshid Jamali 3 &
Fatemeh Kokabisaghi 1 , 4

BMC Health Services Research volume 24 , Article number: 1001 ( 2024 ) Cite this article

Metrics details

The primary purpose of international aid is to promote economic and social development around the world. International aid plays an important role in Afghanistan’s healthcare system. The purpose of this study is to investigate international aid management in Afghanistan’s health sector from the perspectives of national and international managers in 2022 and to provide recommendations for the improvement.

Design/methodology/approach

The study has a cross-sectional design. The study participants were chosen by random sampling. The sample size was determined based on Yaman’s formula at 110. The data collection tool was the questionnaire provided by International Health Partnership and Related Initiatives. The data were analyzed in two descriptive (mean and percentage) and analytical formats. Independent t-test, Mann-Whitney, Kolmogorov-Smirnov tests and Variance analysis were used to examine the relationships between demographic variables and the scores of each dimension.

The average scores given to different dimensions of aid management were as following: 1) the donners’ support of the national health strategy: 48/68 ± 16.14 (49%), 2) the predictable financing: 50/23 ± 16.02 (50%), 3) foreign aid on budget: 55/39 ± 20.15 (55%), 4) strengthening public financial management system: 38/35 ± 19.06 (38%), 5) strengthening the supply and procurement system: 40.97 ± 19.55 (41%), 6) mutual accountability: 46.50 ± 19.26 (46%), 7) technical support and training: 50.24 ± 17.33 (50%), 8) civil society involvement: 35.24 ± 18.61(35%), 9) private sector participation: 36 ± 17.55 (36%), and in total the average score was 44.52 ± 13.27 (44%). The difference between the scores given by two groups of managers was not significant. No meaningful relationship was observed between the total score and any of the demographic variables, but there was a weak relationship between work and management experience and total score. The correlation coefficient showed a statistically significant relationship between the different dimensions of the questionnaire. To sum up, the performance in all dimensions of aid management hardly reached 50%. Donors’ support for the national health strategy was not adequate. There were challenges in evidence-based decision-making, developing national health strategies, control and evaluation, the allocation of resources and use of procurement system. The priorities of donors and government were not always similar and mutual responsibility was lacking. Technical assistance and supporting multilateral cooperation are necessary.

Originality/value

Most studies on foreign aid focused on its effects on economic growth, poverty and investment and not aid management processes. Without proper aid management, parts of resources are wasted and aims of aid programs cannot be achieved. This study investigates aid management in a developing country from the perspectives of two main stakeholders, international and national managers.

Research limitations and implications

Data collection coincided with the change of government in Afghanistan. The situation might be different now. Still, this study provides areas for the improvement of aid management in the studied country. Future studies can build upon the findings of this research and conduct in-depth exploration of areas of aid effectiveness and designing detailed programs of improvement.

Practical implications

Instructions of the Paris Declaration on Aid Effectiveness need to be followed. Particularly, civil society involvement and private sector participation should receive attention. A joint plan for improvement and collaboration of different stakeholders is needed.

Peer Review reports

Introduction

Afghanistan’s history is characterized by internal conflicts and wars which destroyed the economy and country’s infrastructures, including the healthcare system [ 1 ]. Afghanistan is highly dependent on international aid. Dependence on international aid is defined when the aid accounts for at least 10% of the Gross Domestic Product (GDP), and in the absence of this aid, the government cannot perform its main functions [ 2 ]. In 2018, the World Bank estimated that international aid constitutes nearly 40% of Afghanistan’s GDP [ 3 ].

Foreign aid has been effective in improving Afghans’ access to education and health services but still 43% of Afghans do not have access to primary health services and 55% live below the poverty line [ 4 ]. The health financing system in this country is fragile due to high out-of-pocket payment and reliance on donors [ 5 ]. The country’s health sector is financed by 72% out-of-pocket payments, 19.4% donations, 5.1% government budget and 3.5 other sources [ 6 ]. Lack of cooperation between the government and donors on how to spend the aid, political instability, low domestic production and investment, drug mafia, and illiteracy decreased the effectiveness of aid in Afghanistan [ 7 ]. The health of Afghans has improved over the past decade; however, because of poor management of health system, corruption, low quality of health services, lack of monitoring and control, the absence of a comprehensive national policy on universal health services coverage and incomplete implementation of development programs, Afghanistan has the lowest health indicators among the countries in the region [ 4 ].

In recent years, a large amount of aid has been delivered to Afghanistan. There are limited studies addressing aid management and effectiveness in this country. Studies mostly focused on the impact of aid particularly economic effects. Better processes and structures prevent waste of resources that can be used for other priorities. Since international aid plays an important and fundamental role in Afghanistan’s healthcare system, and this system is dependent on it, the way international aid is managed is of great and undeniable importance. The current study examined international aid management in the health sector of Afghanistan from the perspectives of health system managers and donors. It provides areas that require attention of policy makers to increase effectiveness.

Literature review

The main purpose of foreign aid is to reduce poverty and increase economic growth and development in recipient countries [ 8 ]. Official development assistance has increased steadily over the past years. Economic growth is a determinant of social development. Studies showed that public expenditure on health and education, and proper income distribution contributed to human development. Study by Gomanee et al. showed effects of international aid on alleviating poverty and infant mortality [ 9 ].

This is difficult to determine the real impact of foreign aid because development is a multi-dimensional issue that can be influenced by multiple stakeholders. Moreover, the methodology and scope of the assessment can bring different results. Foreign aid effectiveness has been questioned in empirical studies [ 10 ]. In some cases, foreign aid has been remarkably effective. However, there are examples of aid failure [ 11 ]. A study in African recipient countries showed that foreign aid did not influence development growth [ 12 ]. Another study on 33 aid receiving countries showed that 1% increase in the health aid share of GDP reduced the infant mortality rate by 0.18%. It suggested that the proper management of health aid in developing countries can help to improve public health in these countries [ 11 ]. Another study showed that foreign aid had positive effects on reducing poverty. Aid targeted at pro-poor programs such as agriculture, education, health and other social services has been effective [ 13 ].

Aid alone is not enough for achieving sustainable development. It can be effective in countries committed to improving public services and infrastructure and eradicating corruption [ 14 ]. Even though the foreign aid has been increased in recent years, the healthcare resources have not been enough to guarantee everyone’s access to primary healthcare. There is need for more foreign aid and national investment. The aid should be sustainable, predictable and long-lasting to support health promotion plans. The provision of aid-dependent healthcare services will be disrupted if the donors decrease or postpone the aid [ 15 ].

The impact of aid and its effectiveness can be influenced by the way aid is managed. There are many problems in the management of international aid. A large amount of the aid is not received by the recipient government and is spent on unnecessary activities, parallel programs, transaction costs, and donors’ office administration. Some aid programs do not focus on the needs and priorities of the recipient country. In addition to improving the situation of the disadvantaged groups in recipient countries, capacity and infrastructure building, and enhancing health system management, and procurement are necessary. They help health system to become independent in future and better use the resources. Some governments believe that conflicts in policymaking lead to the waste of resources. The donors do not have interest in capacity building [ 15 ]. Chung and Hwang believe that donors should not determine where and how the resources be used but collaborate with the government to assess the population needs and set the priorities [ 10 ].

A study in Syria showed that harmonization of aid and collaboration between stakeholders are perquisites of aid effectiveness. During 2016–2019, the aid to this country has not been harmonized and correlated with humanitarian needs instead aligning more with donor policies [ 16 ]. Another study in Pakistan found that foreign aid has had positive impact on health sector, although in long run, the effect was low. The reason might be that the aid has not been successful in institutional development. If the management of health system does not improve, the aid will create a debate burden [ 17 ]. In Ethiopia, the policy “one plan, one budget, one report” and foundation of country ownership and coordination of health partners, donors and governments resulted in accomplishments in healthcare [ 18 ].

Paris Declaration on International Aid Effectiveness 2005 offers a series of strategies to commit international donors to accountability and increase aid effectiveness. This document invites the developing countries to reduce poverty and improve the performance of institutions and eliminate corruption, and the donors to align with the goals of the recipient governments and cooperate with them, optimize the processes and share information to avoid duplication. Developing countries and donors should focus on the results and be accountable for them. Donors and recipient governments should take an integrated approach to aid effectiveness in policy making to improve quality of foreign aid [ 19 ].

Most studies focused on the effects of aid on economic growth, poverty and investment. The underlying assumption in Paris Declaration was that changes in process such as reducing aid fragmentation could increase the impact of aid. The Global Partnership for Effective Development Cooperation 2011 suggests the collaboration of governments, donors, private sector and civil society. Without proper management, international aid cannot help decreasing inequality and promoting development [ 20 ]. Therefore, it is necessary to study aid effectiveness, processes and management.

Data and method

Data and sample size.

This cross-sectional, descriptive and analytical study was conducted in 2022. The research population was the managers of health sector, both public and private, and international institutions based in Herat province of Afghanistan. The participants were chosen by random sampling. Due to the lack of similar studies, the sample size was determined based on Yaman’s formula and considering an error of 5% and the population size of 180, that made 110 people.

The inclusion criteria were at least two years of work experience in the health sector or international organizations. Incomplete questionnaires (more than 50% of the items have not been answered) were excluded from the study.

The data collection tool was the standard questionnaire of the International Health Partnership and Related Initiatives. It constitutes nine main dimensions, including donors’ support for the national health strategy, predictable financing, foreign aid on budget, public finance management system, procurement system, mutual accountability, technical support and training, civil society engagement and private sector participation, each of which has a number of subcategories and a total of 30 questions [ 21 ]. Due to the lack of an Afghan version of this questionnaire, it was translated to local language by two language experts. The content validity of the questionnaire was qualitatively assessed by 5 experts in the health sector in Afghanistan. The ambiguous items were corrected. The internal consistency of the questionnaire was evaluated by consulting 30 healthcare personnel. The stability, balance and homogeneity of the questions were measured through test and retest with the same people and calculating Cronbach’s alpha. The value of Cronbach’s alpha was 0.963, which is an acceptable value and shows the reliability of the tool.

Methodology

The data of this descriptive and analytical study was collected by self-administered approach. Descriptive studies (similar to this one) provide a detailed understanding of a phenomenon, while they might have limited generalizability and potential bias.

Questionnaires were presented to the study participants in person or by phone and email. All methods were performed in accordance with the relevant guidelines and regulations. In this study, the questions were scored from 1 to 5 (very poor to very good). The data was analyzed in two descriptive (mean and percentage) and analytical formats in SPSS. Independent variables were gender, education, managerial level and years of work experience. Scores given to each dimension of aid effectiveness were the dependent variables. Independent t-test (for data with normal distribution) or Mann-Whitney test (for data with non-normal distribution) were used to examine the relationships of the scores of dimensions and independent variables such as gender. Variance analysis was used to examine the relationships of scores and multivariate variables (such as education, age, work experience). Variance analysis shows the data’s volatility and consistency, which can impact the interpretations of the results. The normality of data distribution of quantitative variables was evaluated using the Kolmogorov-Smirnov test. It is used when there are two samples coming from two populations that can be different. The significance level of the tests was considered 5%.

Descriptive statistics

The average age of the study participants was 42.81 ± 8.36, the average work experience was 14.65 ± 6.06 years, and the average management experience was 10.25 ± 5. In addition, 96 people (87.3%) were men, 48.6% had a bachelor’s degree, and 41.3% a master’s degree. 73 people (67%) were middle-ranked managers. 74 people (67.3%) worked with international organizations and 85.5% completed a training course related to international aid. The knowledge of 15.1% of participants on international aid management was at average level. 64.5% of the participants received information about aid management at their workplace. 71 respondent (66.4%) studied medical and health programs (Table 1 ).

Empirical findings

The results of the survey showed that the highest scores were for foreign aid on budget (39/55 ± 20.15), technical support and training (42/50 ± 17.33), and predictable financing (23/50 ± 16.02) and the lowest score was in the field of civil society participation (35.24 ± 18.61) (Table 2 ). The performance in all dimensions of aid management hardly reached 50%.

More details about the dimensions of evaluation are provided in Table 3 . According to this table, the scores in all dimensions were in the range of 30–56. The lowest scores belonged to civil society participation. In general, the scores were very low and proved that all areas of aid management need improvement.

According to Table 4 , the managers of Afghanistan’s health sector and international organizations based in this country gave the lowest scores to the participation of civil society and the private sector in international aid programs, and the highest scores to considering the foreign aid in the budget. They had similar opinions about different dimensions of international aid management (Table 4 ).

The relationships between independent variables (gender and education) and the scores of different dimensions of aid management showed no meaningful difference. There were no changes in the dependent variable due the manipulation of these two independent variables. However, between managerial level and work experience with the scores, there was week relationship (Table 5 ).

The correlation coefficient showed that between the different dimensions of the questionnaire, there were meaningful relationships which mean the variables change together in the same direction. This indicates the strength of the linear relationship between variables. (Table 6 ).

In this cross-sectional study, international aid management in health sector of Afghanistan has been investigated from the perspective of the managers of health facilities and international organizations based in Herat province in 2022. The average age of study participants was 42.81 ± 36.8, the average work experience was 14.65 ± 6.06 years, and management experience of 10.25 ± 5.83 years. The majority of participants were men, had a bachelor’s degree and worked in middle management positions. A large number of participants worked with international organizations and mostly completed training course related to international aid management. Most of the participants were medical and health graduates. One third of them had fair knowledge about international aid management. The majority acquired the knowledge through work experience.

The managers of Afghanistan’s health system and international organizations believed that the management of international aid in health system of this country was at average level (score: 44.52 ± 13.27 (44% achievement).The performance was better in the dimension of aid on budget (55%) and the lowest was related to civil participation (36%). A study by the Organization for Economic Cooperation and Development (OECD) in 34 aid recipient countries showed that all countries were lagging behind the goals set in the Paris Declaration and needed more efforts and cooperation to improve the situation [ 22 ]. A study conducted in 2009 on the effectiveness of international aid in Afghanistan showed that the conditions in this country brough about challenges for the effectiveness of aid. These include: persistent insecurity, lack of national and international capacity, multiple and often inconsistent programs, ambiguous goals, unclear lines between military, humanitarian, and development interventions, widespread corruption, and lack of coordination among donors [ 23 ].

Donors’ support for the national health strategy was not adequate in Afghanistan (score: 50/23 ± 16.02 (50% achievement). There are challenges in developing national health strategies, control and evaluation of health services, evidence based decision-making and the use of national frameworks. A study in 2020, which investigated the impact of international aid on the growth of Afghanistan’s economy, found factors such as the non-cooperation of the Afghan government and donor countries as an obstacle to aid effectiveness. According to this study, in Afghanistan, there is neither an efficient and effective government institution, nor there are appropriate strategies on the use of international aid [ 24 ]. Similarly, the study on the international aid effectiveness in Ethiopia showed that the aid was scattered and there was no coordination between donors and the government and mutual accountability [ 25 ]. A study conducted on international aid dependence and political agreements in Afghanistan showed that aid was usually allocated based on the preferences of the donors rather than the priorities of the recipient country. Aid has largely focused on short-term goals, hindering medium- and long-term progress. Moreover, the aid may not be under the control of the recipient country [ 2 ]. Studies on foreign aid in other countries, including Nepal, showed that lack of attention to national preferences disrupted proper response to people’s needs [ 26 ].

Sometimes, the priorities are defined at global, regional or multi-country programs and often they are not completely aligned with national policies [ 27 ]. According to the World Health Organization (WHO), doners and the recipient countries might have different views on population needs [ 28 ]. Donors have different histories, experiences, and ideas that affect the projects they prefer to support. Sometimes, the lack of coordination and insularity greatly reduce the effectiveness of aid. For example, there are many international institutions and non-governmental organizations operating in Mali. Each of them has its own strategy, values, culture and work process. Acting in isolation and not integrating the goals with the national policies and structure and the lack of cooperation between the private and public sectors have reduced the effectiveness of aid in recent years [ 29 ]. In the allocation of the aid, the less considered issues are usually the goals of the recipient country [ 30 ]. The lack of coordination between donors is the most important challenge of aid management. Sustainable and effective change depends on the institutionalization of all policies at the local level [ 31 ]. A study by the African Development Bank in 2011 showed that the conflict of interests, weakness of the structures and the lack of capacity were the main challenges of international aid effectiveness. Short-term perspectives disrupt long term development plans [ 32 ].

The predictability of financing received an average score (55/39 ± 20.15 (55% achievement)) in this study which shows that the distribution of health financial resources, allocating aid based on the predetermined plans, and financing health centers through government’s long-term budget and the knowledge of the government on international donors’ programs are problematic. In a study by the Asian Development Bank in 2011, the predictability of development cooperation in Asian countries was evaluated at 78%, which was higher than Afghanistan [ 32 ]. To increase the predictability, it is necessary to have a comprehensive and transparent information system. A case study on international aid effectiveness in health sector of Ethiopia showed that no systematic and comprehensive data on the flow of aid was available [ 25 ]. In a study investigating the management of international aid in a developing country showed that transparency was an important indicator for identifying the problems, weaknesses and gaps in various areas of economic development. The study concluded that it is necessary to increase the involvement of interest groups in formulating strategies and policies [ 33 ].

According to the study participants, about 55% of international aid was placed in national budget. The donors set different strategies in this regard. For example, Italy recognizes the full ownership of the country’s health and medical institutions and gives the responsibility to implement the interventions to the local authorities in Afghanistan [ 34 ]. In contrast, spending a large part of Germany’s aid outside the Afghan government’s system has weakened the government and harmed the accountability of aid recipient institutions [ 35 ]. Similarly, conflicting programs or overlapping projects implemented by different donors reduced the effectiveness of aid according to Albanians [ 33 ]. In Africa, international aid does not flow through the government’s budget system, and is spent by non-governmental organizations or individuals. Local governments do not have enough information about the resources and projects [ 36 ]. Another study on the flow of aid in programs to fight tuberculosis, AIDS and malaria showed that there was no coherence between aid at the national level; aid was not flexible and a small part of it entered the government budget [ 27 ]. In a study that examined international aid management in Ethiopia, it was found that the government played an important role in coordinating international aid. In this country, there are specific national health programs in which the role of international aid is clear [ 25 ].

According to the respondents of this study, strengthening the financial management system of the public sector was not a priority for the donors (achieving 38% of the standard). WHO, in coordination with all key stakeholders in Afghanistan, helps to increase overall resources for health and improve the effectiveness of the investments [ 37 ]. However, the study by Dastan et al. about the determinants of financial protection in the health sector of Afghanistan showed that there was an urgent need to strengthen the overall health financing system in order to promote public health in this country [ 38 ]. Besharat Hossein reviewed the effects of international aid in Bangladesh and said the aid had little effectiveness due to the limited capacity of Bangladeshi institutions. If the government reforms its institutions and policies, foreign aid can contribute more effectively to the national economy [ 39 ]. In another study conducted by the United Nations Conference on Trade and Development (UNCTAD) on international aid allocated to less developed countries, found that donors’ financial resources can be hardly tracked due to the lack of a financial information system. The absence of transparency in spending resources reduced the donors’ trust [ 31 ]. A study in Sri Lanka showed that inefficiency of financial resources and weak institutions made foreign aid ineffective. In addition to effective policies, proper monitoring system supported by donors, and preventing the misuse of resources are needed [ 40 ].

Strengthening the supply system of the recipient country is an important part of aid management. It was scored 40.97 ± 19.55 (41% achievement). In Afghanistan, this aspect has not received enough attention. The donors’ support and use of the national procurement system need improvement. A study on the pros and cons of foreign aid in Albania indicated that donors were reluctant to use Albania’s public procurement systems. Strategic agreements between donors and the government, and forming working groups were suggested to adjust the aid flow [ 41 ]. The study of the Asian Development Bank on aid recipient countries showed that 47% of the aid flows through the public procurement systems. Further coordination between governments and donors is necessary [ 32 ]. The results of this study are similar to the present study.

In the current study, mutual responsibility of the donors and the government was not optimum (score:46.50 ± 19.26 (46% achievement)). There should be an evaluation system agreed with two parties. According to the report of the OECD, the mutual accountability in Afghanistan is a serious challenge, especially since the government and the donors insist on their own political goals, which creates an atmosphere of distrust and makes the implementation of programs difficult [ 22 ]. Asian Development Bank in 2011 indicated that countries were scored 54% in establishing mutual accountability and supporting the government in achieving its goals [ 32 ]. A study on foreign aid policy and its effect on Nepal’s growth showed that the capacity of country’s economy to implement programs was less than satisfactory due to the lack of proper information system and regular monitoring [ 42 ]. In Nigeria, the donors needed to monitor the implementation of plans and effective use of foreign aid. Without making political, economic and institutional reforms, the massive influx of foreign aid will be futile [ 43 ]. A review of foreign aid in Africa in 2012 concluded that responsible governance in this continent is a key to economic development [ 44 ].

Technical support and training help the recipient countries to better contribute in implementing the programs. Considering technical assistance in national programs and health strategies and supporting multilateral cooperation are necessary. The score of technical support in this study was 50.24 ± 17.33 (50%). The study of the Asian Development Bank showed that 45% of the donors paid attention to capacity building and education in recipient countries [ 32 ]. The Geneva Conference 2018 addressed the development of infrastructure and sustainable development in developing countries. The Kabul Conference 2010 focused on the rule of law and good governance and development. The International Monetary Fund supported establishing flexible and sustainable systems for health in Afghanistan [ 45 ]. In recent years, the spending on improving health sector management and policymaking has increased significantly. The aid focused on strengthening the health system through capacity building and planning [ 46 ]. In the absence of a proper support system, the aid is spent on daily affairs and does not lead to the transfer of technology and enhancing the capabilities of the country [ 47 ].

According to the WHO, low salaries and inappropriate working conditions discouraged the few skilled managers and entrepreneurs to participate in international aid projects in Afghanistan. The shortage of female healthcare providers is evident in this country [ 28 ]. The United States Agency for International Development (USAID) launched a midwifery training program to increase the number of female health workers and give women more access to necessary care. USAID created a system for monitoring and supported national diseases information system [ 48 ]. A study showed the need for skilled and knowledgeable managers committed to national values, and teamwork to determine priorities and establish a strong monitoring system. Unbalanced distribution of resources, lack of coordination, unnecessary costs, low efficiency and the lack of infrastructure are among the challenges of the country’s reconstruction process [ 49 ]. There have been various studies on the effectiveness of training provided by donors. The program of transferring technical skills to Afghan government employees by Germany has not been successful enough due to the lack of a monitoring system. Trained employees would not like to work in government facilities due to low wages. After acquiring the necessary skills, they are attracted to non-governmental organizations. Enhancing aid effectiveness requires a change in human resources strategies and enhancing security [ 35 ].

Civil society involvement in health sector programs and development is essential. The society should be empowered by receiving information, technical support and opportunities to participate. The Ministry of Health and the World Bank play important roles in supporting healthcare projects through non-governmental organizations [ 50 ]. However, this study showed that civil participation was not adequate (score: 35.24 ± 18.61, (35% achievement). A study in Albania concluded that the technical assistance and capacity building provided by donors and increasing the awareness of the civil society were among the benefits of aid assistance [ 41 ]. in Nepal, civil participation in country’s development is a challenge. Similar to Afghanistan, this country has religious and linguistic diversity, which together with its uneven terrain and inefficient government acts as an obstacle to national unity for growth [ 42 ]. Civil society needs information to participate in aid management. This information should be understood and analyzed by the civil society and encourage cooperation [ 51 ]. According to OECD, non-governmental organizations and the private sector are weak in developing countries. Lack of capacity hiders them to play their role in the development of the country [ 22 ].

Private sector participation received the lowest score (36 ± 17.55 (36% achievement), among different dimensions of aid management in Afghanistan. Private sector participation in the development and implementation of health sector policies needs donors’ support, information, and financial and technical assistance. The donors can achieve the goals of aid with the support of the private sector and the government. Because of people’s lack of trust to the government administrative system and the desire to achieve tangible results, the private sector compete with government organizations in attracting donated resources, but still they are depended on the support of the government. Some countries, such as the Netherlands, make financial support subject to allocating a part of the aid budget to non-governmental organizations. But, in low-income countries, this organizations do not have enough skills, information and power to cooperate with donors [ 52 ].

In recent years, the private sector has grown in Afghanistan. The government is determined to develop a solid policy framework and establish institutions and systems aimed at ensuring higher quality private services and a long-term and sustainable role for the private sector. Afghanistan is at the beginning of privatization; evidence shows that the Ministry of Health can promote a more efficient and effective private sector [ 53 ]. Based on the report of the UNCTAD, if donors cooperate with the private sector and civil society to set priorities and implement programs, the aid can be effective [ 31 ].

The performance in all dimensions of aid management hardly reached 50%. The managers of Afghanistan’s health sector and international organizations based in this country believed that international aid management in Afghanistan’s health sector needs to be improved. The standards of the Paris Declaration on Aid Effectiveness could be helpful in this regard. According to the studied managers, the best dimension of aid management was the inclusion of international aid in government budget. However, civil society involvement and the private sector participation in planning and implementing aid programs was not satisfactory.

This study showed the areas of aid management that needs improvement in Afghanistan. According to the results, in order to improve international aid management, it is necessary to improve the resources management with the cooperation of international donors, to strengthen health planning, and to develop an effective administrative and management system. Promoting transparency, accountability, and fighting against corruption are the perquisites of aid effectiveness. Economic and social development and investment in infrastructure and cooperation between the government and donors and the private sector will improve public governance. Finding ways to reduce the dependence of the health sector on international aid will be a sustainable solution. The government of Afghanistan should determine the needs of its population and direct the aid towards the priorities of the country which cannot be achieved with government budget.

Study limitations and future studies guidelines

Data collection coincided with the change of government in Afghanistan. The participants of the study stated that due to the extensive changes in administrative and management structures and unclear processes, their opinions addressed the situation before the changes in 2021. Still, this study provides areas for the improvement of aid management in the studied country. Future studies can build upon the findings of this research and conduct in-depth exploration of areas of aid effectiveness and designing detailed programs of improvement. A joint plan for improvement and collaboration of different stakeholders is needed.

Data availability

Data are not publicly available to preserve individuals’ privacy.

Abbreviations

Gross Domestic Product

Organization for Economic Cooperation and Development

United States Agency for International Development

World Health Organization

United Nations Conference on Trade and Development

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Noorullah Rashed, Hamidreza Shabanikiya, Leili Alizamani & Fatemeh Kokabisaghi

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FK designed the study and supervised it; NR: collected data and wrote the report; HSH and JJ: designed methods and analysis; LA: wrote the paper;

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Integrated Health and Social Care in England: Ten Years On

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Integrated care under the Coalition (2010–15)