SIXTY-NINTH WORLD HEALTH ASSEMBLY A69/39

Provisional agenda item 16.1 15 April 2016

Framework on integrated,
people-centred health services

Report by the Secretariat

1. The Executive Board at its 138th session in January 2016 noted an earlier version of this report,1
and adopted resolution EB138.R2. The report has been updated (particularly paragraphs 15, 16 and
18−20) in the light of comments made during the Board’s discussion.

2. Despite significant advances in people’s health and life expectancy in recent years, relative
improvements have been unequal among and within countries. Globally, more than 400 million people
lack access to essential health care.2 Where it is accessible, care is too often fragmented or of poor
quality, and consequently the responsiveness of the health system and satisfaction with health
services3 remain low in many countries. For example, fragile and poorly integrated health systems
were crucial contributors to the Ebola virus disease outbreaks in West Africa, and continued lack of
connection between health systems and strengthening capacities within the International Health
Regulations (2005) leaves other countries vulnerable.

3. Many countries still face significant problems of unequal geographical access to health services,
shortages of health workers and weak supply chains. Even for high priority conditions such as
maternal and child health, coverage of basic services (for example, antenatal care and presence of a
skilled birth attendant at delivery) remains low in many countries.4 Continuity of care is also poor for
many health conditions owing to weak referral systems. The focus on hospital-based, disease-based
and self-contained “silo” curative care models further undermines the ability of health systems to
provide universal, equitable, high-quality and financially sustainable care. Service providers are often
unaccountable to the populations they serve and therefore have limited incentive to provide the
responsive care that matches the needs of their users. People are often unable to make appropriate
decisions about their own health and health care, or exercise control over decisions about their health
and that of their communities.

1
See document 138/37 and the summary record of the Executive Board at its 138th session, tenth meeting, section 2
(document EB138/2016/REC/2).
2
WHO, The World Bank. Tracking universal health coverage: first global monitoring report. Geneva: World Health
Organization; 2015, available online at: http://apps.who.int/iris/bitstream/10665/174536/1/9789241564977_eng.pdf?ua=1,
accessed 4 April 2016.
3
Definition: health services: health services include all services dealing with the promotion, maintenance and
restoration of health. They include both personal and population-based health services.
4
Countdown to 2015: maternal, newborn and child survival. Country profiles. Available at: http://www.countdown
2015mnchcountdown2015mnch.org/country-profiles, accessed 4 April 2016.
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4. Making progress towards the United Nations’ Sustainable Development Goal 3 (Ensure health
lives and promote well-being for all at all ages), including target 3.8 on universal health coverage,
requires countries to move towards ensuring that all people and communities have access to health
services that are high quality, safe and acceptable. Cost-efficient, effective approaches to service
delivery must be maximized for this to be attainable and sustainable. An integrated,1 people-centred2
approach is crucial to the development of health systems that can respond to emerging and varied
health challenges, including urbanization, the global tendency towards unhealthy lifestyles, ageing
populations, the dual disease burden of communicable and noncommunicable diseases, multi-
morbidities, rising health care costs, disease outbreaks and other health-care crises.

5. Developing more integrated people-centred care systems has the potential to generate
significant benefits to the health and health care of all people, including improved access to care,
improved health and clinical outcomes, better health literacy and self-care, increased satisfaction with
care, improved job satisfaction for health workers, improved efficiency of services, and reduced
overall costs.

6. In 2009, the Health Assembly adopted resolution WHA62.12, urging improvements in primary
health care and health system strengthening and requesting the Director-General to prepare
implementation plans for the four broad policy directions, including putting people at the centre of
service delivery, and to ensure that these plans span the work of the entire Organization. In addition,
resolution WHA64.9 (2011) on sustainable health financing structures and universal coverage,
adopted in 2011, urges Member States to continue, as appropriate, to invest in and strengthen the
health-delivery systems, in particular primary health care and services, in order to ensure that all
citizens have equitable access to health care, and to ensure that overall resource allocation strikes an
appropriate balance between health promotion, disease prevention, rehabilitation and health-care
provision. United Nations’ General Assembly resolution 64/265 in 2010 on prevention and control of
non-communicable diseases and the subsequent high-level meeting on the prevention and control of
non-communicable diseases (New York, 19–21 September 2011)3 recommended a focus on primary
care to deliver “prioritized packages of essential interventions”. Moreover, the General Assembly in
its ensuing Political Declaration inter alia encouraged the supporting of primary health care and the
empowerment of people for self-care.

7. Strategic documents and resolutions from all WHO regions and regional committees also call
for a more integrated, people-centred approach to health service delivery. These include the “Road
map for scaling up the human resources for health for improved health service delivery in the African
Region 2012–2025” endorsed by the Regional Committee for Africa in resolution AFR/RC62/R3;

1
Definition: integrated health services: health services that are managed and delivered so that people receive a
continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative
care services, coordinated across the different levels and sites of care within and beyond the health sector, and according to
their needs throughout the life course.
2
Definition: people-centred care: an approach to care that consciously adopts individuals’, carers’, families’ and
communities’ perspectives as participants in, and beneficiaries of, trusted health systems that are organized around the
comprehensive needs of people rather than individual diseases, and respects social preferences. People-centred care also
requires that patients have the education and support they need to make decisions and participate in their own care and that
carers are able to attain maximal function within a supportive working environment. People-centred care is broader than
patient and person-centred care, encompassing not only clinical encounters, but also including attention to the health of
people in their communities and their crucial role in shaping health policy and health services.
3
Report of the Secretary-General, document A/66/83
(http://www.un.org/en/ga/search/view_doc.asp?symbol=A/66/83&Lang=E, accessed 4 April 2016).

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resolution CD49.R22 on integrated health service delivery networks based on primary health care and
resolution DC52/5 on social protection as well as the “Strategy for universal access to health and
universal health coverage” in the Region of the Americas; the regional strategy for universal health
coverage endorsed by the Regional Committee for South-East Asia in resolution SEA/RC65/R6;
“Health 2020” (adopted in resolution EUR/RC62/R4) and “Towards people-centred health systems: an
innovative approach for better health systems”1 in the European Region; resolution EM/RC60/R.2 on
universal health coverage, which calls for the expansion of the provision of integrated people-centred
health services that address the major burden of ill-health and are based on primary health care, and
the “Framework for action on advancing universal health coverage in the Eastern Mediterranean
Region”;2 and resolution WPR/RC58.R4 which endorsed the policy framework on people-centred
health care as a guide for Member States to develop and implement people-centred health care policies
and interventions according to their national contexts and the action framework on human resources
for health in the Western Pacific Region 2011–2015.3

8. In response, the Secretariat began an organization-wide collaboration in 2013 to produce a

framework on integrated, people-centred health services. A consortium of leading research institutions
was commissioned to produce a draft which was reviewed by Member States and experts from the
donor community, civil society representatives, representatives from research institutions and the
Secretariat in October 2013, resulting in the completion of a second draft by end of April 2014. The
interim framework on integrated, patient centred health services report was published in March 2015,
after further consideration in the light of the draft global strategy on human resources for health:
Workforce 2030.4

9. The interim report was reviewed through an extensive consultation process, including: a web-
based public consultation open to individuals and organizations and regional and Member State
consultations. The Secretariat has collated the relevant input in order to update the framework.
Respondents have shown extensive support for the proposed vision, the strategies and the
implementation approach.

10. Pursuant to resolution WHA62.12 on primary health care, including health system strengthening
and other related resolutions, this framework proposes five interdependent strategies for health
services to become more integrated and people-centred. It calls for reforms to reorient health services,
putting individuals, families, carers and communities at their centre, supported by responsive services
that better meet their needs, and that are coordinated both within and beyond the health sector,
irrespective of country setting or development status. These reforms also incorporate a human rights
approach, enshrining access to health care as a basic right, without distinction of ethnicity, religion,
gender, age, disability, political belief, and economic or social condition.

1
WHO Regional Office for Europe. Towards people-centred health systems: an innovative approach for better health
systems. Copenhagen, Regional Office for Europe available at http://www.euro.who.int/__data/assets/pdf_file/0006/186756/
Towards-people-centred-health-systems-an-innovative-approach-for-better-health-outcomes.pdf, accessed 4 April 2016.
2
http://applications.emro.who.int/docs/Technical_Notes_EN_16287.pdf, accessed 4 April 2016.
3
http://www.wpro.who.int/hrh/documents/HRH_Action_Framework.pdf, accessed 4 April 2016.
4
The full draft framework along with its accompanying “overview of the evidence” document can be accessed on the
WHO website, at http://www.who.int/servicedeliverysafety/areas/people-centred-care/en/ (accessed 4 April 2016).

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FRAMEWORK ON INTEGRATED PEOPLE-CENTRED HEALTH SERVICES IN

BRIEF1

11. The draft framework sets forth a compelling vision in which “all people have equal access to
quality health services that are co-produced2 in a way that meets their life course needs, are
coordinated across the continuum of care, and are comprehensive, safe, effective, timely, efficient and
acceptable; and all carers are motivated, skilled and operate in a supportive environment”. The
framework is based on experience and evidence gained recently in different countries and
wide-ranging consultation with experts at the global, regional and national levels, informed by related
global policy commitments, regional strategies and initiatives in the area of universal health coverage,
health systems strengthening, social determinants of health, and the core values and principles of
primary health care: the right to health, social justice, solidarity and participation.

12. Realization of integrated people-centred health services will depend on health system inputs,
including the availability, accessibility and quality of health workers and the services they provide.
The draft global strategy on human resources for health outlines the medium-term actions needed to
ensure equitable access to a skilled and motivated health workforce within a fully functioning health
system. As such, efforts have been made to form firm links between the framework on integrated,
people-centred health services and the global strategy, including aligning human resources for health
investment frameworks at national and global levels to future needs of health systems. Integrated,
people-centred health services require particular health workers with relevant skills. In addition to the
benefits to communities and populations, the benefits of an integrated people-centred care approach
also extend to health workers, including: improved job satisfaction; more balanced workloads and
fewer instances of burnout; and education and training opportunities to learn new skills, such as
working in team-based health care environments.

13. For the development of this framework, four different types of country settings have been
analysed: low-, middle- and high-income countries, and countries facing special circumstances, such
as conflict, and fragile States, small island States and large federal States. Given that health systems
are highly context-specific, the framework does not propose a single model of people-centred and
integrated health services. Instead, it proposes five interdependent strategies that need to be adopted.

STRATEGIES, POLICY OPTIONS AND INTERVENTIONS

14. The five interdependent strategies are: (1) empowering and engaging people and communities;
(2) strengthening governance and accountability; (3) reorienting the model of care; (4) coordinating
services within and across sectors; and (5) creating an enabling environment. Attainment of these five
strategies cumulatively will help to build more effective health services; lack of progress in one area
will potentially undermine progress in other areas.

1
See http://www.who.int/servicedeliverysafety/areas/people-centred-care/en/ (accessed 4 April 2016).
2
Definition: co-production of health: care that is delivered in an equal and reciprocal relationship between
professionals, people using care services, their families and the communities to which they belong. It implies a long-term
relationship between people, providers and health systems where information, decision-making and service delivery become
shared.

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15. Action towards each strategy is intended to have an influence at different levels – from the way
services are delivered (to individuals, families and communities) to changes in the way organizations,
care systems and policy-making operate. Strategic approaches, potential policy options and
interventions are detailed in the Table for the attainment of each strategy. Some of these potential
policy options and interventions are cross-cutting for several strategic approaches. This
non-exhaustive list has been drafted on the basis of literature reviews, input from technical
consultations and expert opinion; it does not constitute a set of evidence-based guidelines for reform,
as the evidence base for some of these policies and interventions is not fully established. Moreover,
the appropriate mix of policies and interventions to be used at the country level will need to be
designed and developed according to the local context, values and preferences.

Table. Strategies, policy options and interventions for the framework on integrated,
people-centred health services

Strategy 1: Empowering and engaging people and communities

Empowering and engaging people is about providing the opportunity, skills and resources that people need to be
articulate and empowered users of health services and advocates for a reformed health system. This strategy
seeks to unlock community and individual resources for action at all levels. It aims to empower individuals to
make effective decisions about their own health and to enable communities to become actively engaged in
co-producing healthy environments, and to provide informal carers with the necessary education to optimize
their performance and support in order to continue in their role. Empowering and engaging people is also about
reaching the underserved and marginalized groups of the population in order to guarantee universal access to
and benefit from quality services that are co-produced according to their specific needs.
Strategic approach Policy options and interventions
1.1 Empowering and engaging individuals and families. In • health education1
order to achieve better clinical outcomes through co-production • informed consent
of care, particularly for noncommunicable and chronic diseases, • shared clinical decision making between
individuals and families need to be active participants. This step individual, families, carers and providers
is fundamental because people themselves will spend the most • self-management including personal care
time living with and responding to their own health needs and assessment and treatment plans
will be the ones making choices regarding healthy behaviours • knowledge of health system navigation
and their ability to self-care. Empowerment is also about care that
is delivered in an equal and reciprocal relationship between, on
the one hand, clinical and non-clinical professionals and, on the
other, the individuals using care services, their families, and
communities, thereby improving their care experience.
1.2 Empowering and engaging communities. This approach • community delivered care
will enable communities to voice their needs and so influence the • community health workers
way in which care is funded, planned and provided. It will help to • development of civil society
build confidence, trust, mutual respect and the creation of social • strengthened social participation in health
networks, because people’s physical and mental well-being
depends on strong and enduring relationships. It strengthens the
capacity of communities to organize themselves and generate
changes in their living environments.

1
Definition: health education: any combination of learning experiences designed to help individuals and
communities improve their health, by increasing their knowledge or influencing their attitudes.

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 1.3 Empowering and engaging informal carers. Family • training for informal carers
members and other care-givers play a critical role in the provision • informal carer networks
of health care. Carers must receive adequate training in order to • peer support and expert patient groups
be able to provide high quality interventions, and to serve as • caring for the carers
advocates for the recipients of care, both within the health system • respite care
and at the policy level. Additionally, carers have their own needs
for personal fulfilment and require emotional support to sustain
their role.
 1.4 Reaching the underserved and marginalized. This • integration of health equity goals into
approach is of paramount importance for guaranteeing universal health sector objectives
access to quality health services. It is essential for fulfilling • provision of outreach services for the
broader societal goals such as equity, social justice and solidarity, underserved including mobile units,
and helps to create social cohesion. It requires actions at all levels transport systems and telemedicine
of the health sector, and concerted action with other sectors and • outreach programmes for
all segments of society, in order to address the other determinants disadvantaged/marginalized populations,
of health and health equity. who may not receive effective coverage
owing to barriers linked to factors that
include income, education, residence,
gender, ethnicity, working conditions or
migrant status
• contracting out of services when
warranted
• expansion of primary care-based systems

Strategy 2: Strengthening governance and accountability

Strengthening governance requires a participatory approach to policy formulation, decision-making and

performance evaluation at all levels of the health system, from policy-making to the clinical intervention level.
Good governance is transparent, inclusive, reduces vulnerability to corruption and makes the best use of
available resources and information to ensure the best possible results. Good governance is reinforced by a
robust system for mutual accountability among policy-makers, managers, providers and users and by incentives
aligned with a people-centred approach. Establishing a strong policy framework and a compelling narrative for
reform will be important to building a shared vision, as well as setting out how that vision will be achieved.
Strategic approach Policy options and interventions
2.1 Bolstering participatory governance. Robust governance • community participation in policy
mechanisms are needed in order to achieve a coherent and formulation and evaluation
integrated approach in health care policy, planning and delivery • community representation at health care
at all levels of the health system. Governments need to take facilities’ boards
responsibility for protecting and enhancing the welfare of their • national health policies, strategies and
populations and to build trust and legitimacy with citizens plans promoting integrated people-
through effective stewardship. The stewardship role of the health centred health services
ministry is essential for good governance in health, and involves • strengthened health services governance
the identification and participation of community stakeholders so and management at subnational, district
that voices are heard and consensus is achieved. It is also needed and local levels
to ensure that the different goals of donor agencies and vertical • harmonization and alignment of donor
programmes tackling specific diseases do not hinder the ability of programmes with national policies,
health systems to focus on community health and well-being for strategies and plans
all. • decentralization, where appropriate, to
local levels
• comprehensive planning across the
public/private sector

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• strengthened stewardship role of the

health ministry in respect of non-State
actors
• clinical governance
2.2 Enhancing mutual accountability. Essentially, this means • health rights and entitlement
answerability of decision-making, and encompasses both the • provider report cards
“rendering of the account” (that is, providing information about • patient satisfaction surveys
performance) and the “holding to account” (namely, the • patient reported outcomes and balanced
provision of rewards and sanctions). Strengthening accountability scorecard
of health systems requires joint action at all levels to improve • performance based financing and
services organization and delivery, health policy in health and contracting
non-health sectors, public and private sectors, and people, • population registration with accountable
towards a common goal. care provider(s)

Strategy 3: Reorienting the model of care

Reorienting the model of care means ensuring that efficient and effective health care services are designed,
purchased and provided through innovative models of care that prioritize primary and community care services
and the co-production of health. This encompasses the shift from inpatient to outpatient and ambulatory care and
from curative to preventive care. It requires investment in holistic and comprehensive care, including health
promotion and ill-health prevention strategies that support people’s health and well-being. It also respects
gender and cultural preferences in the design and operation of health services.
Strategic approach Policy options and interventions
3.1 Defining service priorities based on life course needs. • local health needs assessment based on
This approach means appraising the package of health services existing patterns of communicable and
offered at different levels of the care delivery system based on noncommunicable diseases
the best available evidence, covering the entire life course. It uses • comprehensive packaging of services for
a blend of methods to understand both the particular health needs all population groups defined by means of
of the population, including social preferences, and the cost- a participatory and transparent process
effectiveness of alternative health interventions, guiding decision • strategic purchasing
making on allocation of resources to health care. It also includes • gender, cultural and age-sensitive
health technology assessment. services
• health technology assessment
3.2 Revaluing promotion, prevention and public health. This • monitoring population health status
approach means placing increased emphasis and resources on • population risk stratification
promotive, preventive and public health services. Public health • surveillance, research and control of risks
systems include all public, private, and voluntary entities that and threats to public health
contribute to the delivery of essential public health functions • improved financial and human resources
within a defined geographical area. allocated to health promotion and disease
prevention
• public health regulation and enforcement
3.3 Building strong primary care-based systems. Strong • primary care services with a family and
primary care services are essential for reaching the entire community-based approach
population and guaranteeing universal access to services. • multidisciplinary primary care teams
Building such services involves ensuring adequate funding, • family medicine
appropriate training, and connections to other services and • gatekeeping to access other specialized
sectors. This approach promotes coordination and continuous services
care over time for people with complex health problems, • greater proportion of health expenditure
facilitating intersectoral action in health. It calls for allocated to primary care
interprofessional teams to ensure the provision of comprehensive
services for all. It prioritizes community and family-oriented
models of care as a mainstay of practice with a focus on disease
prevention and health promotion.

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3.4 Shifting towards more outpatient and ambulatory care. • home care, nursing homes and hospices
Service substitution is the process of replacing some forms of • repurposing secondary and tertiary
care with those that are more efficient for the health system. The hospitals for acute complex care only
approach means finding the right balance between primary care, • outpatient surgery
specialized outpatient care and hospital inpatient care, • day hospitals
recognizing that each has an important role within the health care • progressive patient care
delivery system.
3.5 Innovating and incorporating new technologies. Rapid • shared electronic medical record
technological change is enabling the development of increasingly • telemedicine
innovative care models. New information and communication • mHealth
technologies allow new types of information integration. When
used appropriately, they can assure continuity of information,
track quality, facilitate patients’ empowerment and reach
geographically isolated communities.

Strategy 4: Coordinating services within and across sectors

Services should be coordinated around the needs and demands of people. This result requires integration of
health care providers within and across health care settings, development of referral systems and networks
among levels of care, and the creation of linkages between health and other sectors. It encompasses intersectoral
action at the community level in order to address the social determinants of health and optimize use of scarce
resources, including, at times, through partnerships with the private sector. Coordination does not necessarily
require the merging of the different structures, services or workflows, but rather focuses on improving the
delivery of care through the alignment and harmonizing of the processes and information among the different
services.
Strategic approach Policy options and interventions
4.1 Coordinating care for individuals. Coordination of care is • care pathways
not a single activity, but rather a range of strategies that can help • referral and counter-referral systems
to achieve better continuity of care and enhance the patient’s • health navigators
experience with services, particularly during care transitions. The • case management
focus for improvement is on the delivery of care to the individual, • improved care transition
with services coordinated around their needs and those of their • team-based care
families. This approach also covers improved information flows
and maintenance of trustworthy relationships with providers over
time.
4.2 Coordinating health programmes and providers. This • regional or district-based health service
approach includes bridging the administrative, informational and delivery networks
funding gaps between levels of care and providers. This involves • purchasing integrated services
sector components such as pharmaceutical and product safety • integrating vertical programmes into
regulators, information technology teams working with disease national health systems
surveillance systems, allied health teams delivering treatment • incentives for care coordination
plans in collaboration with each other, disease-specific laboratory
services linked to broader services improvement, and provider
networks focused on closer relationships in patient care.
4.3 Coordinating across sectors. Successful coordination in • health in all policies
health matters involves multiple actors, both within and beyond • intersectoral partnerships
the health sector. It encompasses sectors such as social services, • merging of health sector with social
finance, education, labour, housing, the private sector and law services
enforcement, among others. It necessitates strong leadership from • working with education sector to align
the health ministry to coordinate intersectoral action, including professional curriculum towards new
coordination for early detection and rapid response to health skills needed
crises. • integrating traditional and complementary
medicine with modern health systems
• coordinating preparedness and response
to health crises

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Strategy 5: Creating an enabling environment

In order for the four previous strategies to become an operational reality, it is necessary to create an enabling
environment that brings together all stakeholders to undertake transformational change. This complex task will
involve a diverse set of processes to bring about the necessary changes in leadership and management,
information systems, methods to improve quality, reorientation of the workforce, legislative frameworks,
financial arrangements, and incentives.
Strategic approach Policy options and interventions
5.1 Strengthening leadership and management for change. • transformational and distributed
New forms of collaborative leadership that help to bring together leadership
multiple stakeholders are needed for successful reform of health • change management strategies
services. All health care professionals, and especially clinicians,
need to be engaged in management and leadership for change in
continuous partnership with local communities. Achieving
people-centred and integrated care requires the application of
complex processes and service innovations that warrant an
underlying change management strategy.
5.2 Strengthening information systems and knowledge • development of information systems
management. Development of information systems and an • systems research
organizational culture that supports monitoring and evaluation, • knowledge management
knowledge sharing and using data in decision-making is also a
prerequisite for transformational change.
5.3 Striving for quality improvement and safety. Institutions • quality assurance
and providers need to strive constantly for quality improvement • creating a culture of safety
and safety. These efforts include both technical and perceived • continuous quality improvement
quality.
5.4 Reorienting the health workforce. Special attention needs • tackling health workforce shortages and
to be given to readying the health workforce with an appropriate maldistribution
skills mix in order equitably and sustainably to meet population • health workforce training
health needs. Health workers must be organized around teams • multi-professional teams working across
and supported with adequate processes of work, clear roles and organizational boundaries
expectations, guidelines, opportunities to correct competency • improving working conditions and
gaps, supportive feedback, fair wage, and a suitable work compensation mechanisms
environment and incentives. • provider support groups
• strengthening professional associations
5.5 Aligning regulatory frameworks. Regulation plays a key • aligning regulatory framework
role in establishing the rules within which professionals and
organizations must operate within more people-centred and
integrated health systems – for example, in terms of setting new
quality standards and/or paying against performance targets.
5.6 Improving funding and reforming payment systems. • assuring sufficient health system
Changes in the way care is funded and paid for are also needed to financing and aligning resource allocation
promote adequate levels of funding and the right mix of financial with reform priorities
incentives in a system that supports the integration of care • mixed payment models based on
between providers and settings and protection of patients against capitation
undue out-of-pocket expenditures on health. • bundled payments

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IMPLEMENTATION APPROACH

16. The lessons of history need to be acknowledged: the successful reorientation of health services
will most likely be a long journey and will need sustained political commitment. Ultimately, each
country or local jurisdiction needs to set its own goals for integrated and people-centred health
services, and develop its own strategies for achieving these goals. The strategies must respond to the
local context, existing barriers and the values held by people within the State or area, and should be
achievable given the current health service delivery system and the financial and political resources
available. Efforts should primarily concentrate on improving access to services for underserved and
marginalized populations, on placing increased emphasis and resources on promotive, preventive and
public health services and on strengthening district-level health services, among others. Given that this
framework is fundamentally transformative in its implications for the future of health systems, system
leaders must adopt strategies for change to ensure the effective alignment of strategies and processes
that promote people-centred and integrated care. Delivering high-quality, people-centred care and
integrated health services requires the creation and nurturing of collective engagement, commonly-
held values, effective communication and transparency. The implementation approach, therefore, of
this framework is as follows:

(a) Country-led: strategies for pursuing integrated people-centred health services should be
developed and led by countries, with external support where necessary, and should respond to
local conditions and contexts.

(b) Equity-focused: efforts to enhance equity are a necessary part of people-centred and
integrated health care strategies. Efforts can target immediate factors driving inequitable service
utilization, but may also address more fundamental social determinants.

(c) Participatory: the notion of people-centred and integrated health services puts informed
and empowered people at the centre of the health system. Therefore, processes to develop
national strategies for such services should ensure accountability to local stakeholders and,
especially, to disadvantaged populations.

(d) Systems strengthening: service delivery depends on effective information and financing
systems, and the availability of skilled and motivated health workers. Changes made to service
delivery will inevitably have ramifications across the entire health system.

(e) Evidence-based practice with iterative learning/action cycles: decisions at all levels
should be based on the best available evidence. Quality improvement methodology shows that
success is most likely when there are iterative learning and action cycles that track changes in
the service delivery system, identify emerging problems and bring stakeholders together to
solve them.

(f) Results-oriented: a key focus should be on the ongoing monitoring of progress through
specific and measurable objectives and results.

(g) Ethics-based: by making sure that care optimized the risk benefit ratio in all interventions,
respects the individual’s right to make informed and autonomous decisions, safeguards privacy,
protects the most vulnerable, and ensures the fair distribution of resources.

(h) Sustainable: planning, managing and delivering care that is equitable, efficient, effective
and that contributes to long-term development in a sustainable manner.

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THE ROLE OF STAKEHOLDERS

17. The role of stakeholders in this framework is as follows:

(a) Member States: countries committed to moving towards people-centred and integrated
health services should develop and communicate a clear vision, setting sound strategies and
regulatory frameworks that facilitate the way towards their achievement. This process needs to
be country-led and involves co-production between all government sectors, providers and the
people that they serve. Governments need to secure adequate funding for reform and
implementation research. This process has to be replicated at both subnational and local levels.

(b) Individuals, families and communities: They constitute the main focus of attention of the
framework. Policy formulation, health services organization and co-production of health
services should be developed and implemented in partnership with individuals, families and
communities.

(c) Civil society organizations: as representatives of patients, families, communities and

carers, these organizations have an important role to play in advocating for more people-centred
and integrated health services, as well as in empowering their members to be able to better
manage their own health concerns and engage with the health system.

(d) Health service providers: these constitute a fundamental component of the framework.
Policy formulation, health services organization and co-production of health services should be
developed and implemented in partnership with service providers, as in the case of individuals,
families and communities.

(e) Academic, training and research institutions: these bodies have an important role to play
in developing new professional curricula for the health workforce, training the health workforce,
and conducting health systems and implementation research efforts.

(f) Professional and students associations: these organizations can play important roles in
adopting and endorsing new practices, and in providing support to their members.

(g) Private sector: regulatory steps should be taken to assure that reforms to increase care
integration and people-centredness apply equally to public and private service providers,
including for profit, non-for-profit, and faith-based organizations. Partnerships with private
sector industry, such as pharmaceutical and medical device industries, can also be pursued when
appropriate.

(h) Health insurers: these entities should guarantee sufficient financing for service delivery
reform and reorient payment systems and purchasing practices to incentivise more integrated,
people-centred approaches to care.

(i) Development partners: these should, except under exceptional circumstances where rapid
or unique action is required, seek to integrate their support to health service delivery into
countries’ own health systems. They can also help to share technical knowledge about different
approaches to promoting more people-centred and integrated services.

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(j) Secretariat: the role of the Secretariat will be to drive policies that can support the
development of people-centred and integrated health services across the world. The adoption of
integrated people-centred health services, and the five key strategies identified in this
framework, will therefore require sustained advocacy and technical cooperation efforts.

PROGRESS MONITORING

18. As the framework represents a new programme of work for WHO, there are no universally
utilized indicators to measure progress in establishing integrated people-centred health services. The
Global Health Observatory, the monitoring and evaluation frameworks for universal health coverage
and the Sustainable Development Goals, and the Global Reference List of 100 Core Health Indicators1
– none includes measures of integration or people-centredness. Given this situation, the framework
proposes performing research and development on indicators to track global progress on integrated
people-centred health services. This effort will convene international partners to develop appropriate
metrics for these critical, but less frequently measured domains of health care.

19. The elaboration of these indicators will facilitate the development of the medium- and long-
term goals and targets that are needed to monitor progress in the implementation of the framework at
the global, regional and national levels.

ACTION BY THE HEALTH ASSEMBLY

20. The Health Assembly is invited to adopt the draft resolution recommended by the Executive
Board in resolution EB138.R2.

= = =

1
See http://www.who.int/healthinfo/indicators/2015/en/, accessed 4 April 2016.

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