title: Factors Hindering or Promoting the Integration of Neglected Tropical Diseases Requiring Case Management into the Liberian Health System
Creators: name: Kollie, Karsor K
Publisher: name: University of Liverpool Repository
Year: 2024

description: Introduction
Neglected Tropical Diseases (NTDs), are a group of twenty-one disease conditions that can be prevented, controlled, eliminated or eradicated. They affect more than a billion of the world's poorest populations. Integration of NTD programmes into national health systems is recommended by the NTDs community as a required strategy to maximise scarce resources, improve service delivery and produce the desired health outcomes. Integration of case management (CM) NTDs is seen as a strategy to reach established global health targets including the World Health Organization’s (WHO) 2021-2030 NTDs road map and Universal Health Coverage (UHC). Despite the perceived benefits, there is limited evidence demonstrating the feasibility, impact and critical factors promoting or hindering integration of CM-NTDs. Liberia is the first country to implement the integration approach and the overarching aim of this thesis is to identify and critically evaluate the impact and factors hindering and promoting integration into the Liberian health system.
Methods
I conducted a mixed-method study design primarily using a range of qualitative research methods: key informant interviews, observation diary notes, focus group discussion and in-depth interview to explore the experiences, enablers and challenges to integration of CM-NTDs at various levels of the health system. To supplement this qualitative research, I conducted a quantitative study in the three NTD high-burden counties of Lofa, Bomi, and Maryland using a real-world integration programme with health facility routine data collected on CM-NTDs from 2016 to 2019. For controls, I cluster-matched the three selected counties with non-integrated NTD counties. 
Results
This study found that it was feasible to implement an integrated CM-NTDs model and it was shown to be impactful in Liberia through strengthening the health system’s capacity to increase NTDs service provision leading to better health outcomes, although there were challenges related to early case detection. The qualitative findings illustrate that the perceived benefits and strengths to integrating NTD commodities into the national supply chain include leveraged storage and management capacities and the political will to integrate based on cost-saving. However, challenges included the risk of reliance on donor funding for the supply chain, difficulty in accessing commodities due to bureaucratic bottlenecks, lack of inclusion of NTD commodities within electronic data tools and inability to meet medicine and commodity demand (Kollie et al 2023, Kollie et al 2020). Additionally, challenges with medicine supply and incentives negatively impacted the morale of service providers leading to restricted access creating trust issues between NTD-affected people, the community and the health system. Qualitative findings demonstrate factors that lead to pulling away from integrating additional workloads into the existing health workforce. For example, rigidity of funding, challenges to attributing intervention outcomes to different partners, loss of job titles and benefits and an overwhelming workload. On the other hand, examples of push factors for integrated human resources for health include, collaboration and joint work, changes in managerial structure from a vertical to an integrated one and a shared desire to achieve one health goal. The quantitative finding demonstrates integration improved the overall case detection rate more than fourfold. It enhanced accessibility through provision of training activities, awareness on NTDs prevention and control activities, availability of medicine and medical supplies, and scaling up of CM-NTDs services into the primary health facilities. Some challenges emerged with respect to quality of care.
Conclusion
The integration of CM-NTD programmes leads to better health outcomes contributing to universal health coverage and attaining the targets of the WHO NTDs roadmap. It is challenging and complex working with real-world routine programme data, however, it is important because of its use by programmes for decision-making. These results demonstrate the importance of ongoing multi-method evaluation due to its holistic nature and the exploration of learning within national NTD programmes. Finally, decision makers and programme managers contemplating similar integration approaches should consider a step-by-step approach, beginning with NTDs stakeholders’ consultations and government leadership, prioritise integration through national health policy development and implementation in a country’s context and evaluate through a multi-method approach. The sustainability and equity of service provision of such an integrated approach will require further investigation.