Conceptualizing Integration: A Framework for Analysis Applied to Neglected Tropical Disease Control Partnerships

The timely and sustained delivery of effective health interventions to communities in developing countries is one of the greatest challenges in global health. Millions of the world’s poorest citizens continue to be afflicted by bacterial, viral, and parasitic infections that have persisted, mainly in the tropics—the so-called neglected tropical diseases (NTDs)—despite the availability of safe and cost-effective interventions for the control and elimination of many of these diseases. Access to these interventions (or control tools) remains low and inadequate, particularly in sub-Saharan Africa [1,2]. The NTDs, including onchocerciasis, schistosomiasis, lymphatic filariasis, trachoma, and soiltransmitted helminthiasis, have been shown to affect the poorest of the poor disproportionately. Addressing the NTDs, therefore, will be an essential element in poverty alleviation programs [3,4]. A number of important international single-disease control partnerships have been developed over the last few decades [5–7]. To date, however, there has been little integration among these partnerships [3]. Integration refers to the creation of linkages among existing programs to improve the delivery of health interventions given existing commitments and resources. The presence of many common elements and general arguments about economies of scale provide strong reasons to believe that integration amongst partnerships can help improve both efficiency and effectiveness. Interest in integration is currently at an all-time high, due in part to new funding for integration (the Bill & Melinda Gates Foundation has announced research grants to investigate integration of NTDs, and the United States Agency for International Development [USAID] has awarded operational grants to scale-up integrated NTD control programs), the creation of the Global Network for Neglected Tropical Diseases Control (GNNTDC; http://gnntdc.sabin.org/), and high-level political commitment to address these scourges [8]. In addition, reports of successful national control programs for single diseases supported by these partnerships (such as trachoma control in Morocco and lymphatic filariasis control in Egypt) bolster the case that integration be prioritized in affected countries. While there has been significant discussion about the integration of single-disease partnerships [9–11] and the potential usefulness of such approaches in helping to tackle the burden of NTDs, there is limited experience in implementing integration and even less experience in conducting systematic analysis of these experiences. Recently, a number of articles have discussed potential challenges and opportunities, and have estimated potential benefits, including cost savings [12–14]. The lack of a common understanding of integration for disease control programs may be a significant impediment towards implementing integration, despite significant interest in the topic. This article presents a conceptual framework to help guide the discussion about integration of NTD control partnerships. It then provides specific examples of potential opportunities and actual cases of integration of NTDs, and places these examples within the conceptual framework. The main purpose of this article is to provide a tool for thinking about integration—to aid the development, implementation, and evaluation of future efforts at integrating NTD control programs. This framework could also be used for assessing other forms of integration among service-oriented programs. This article does not provide lessons from ongoing NTD integration efforts, because the existing attempts are at too early a stage to generate results.