Monika Martens

• 14 January 2025
• Time: 5 PM - 7 PM
• Venue: Campus ITM - aula Janssens - Sint Rochusstraat 43 - 2000 Antwerpen and online​
• PhD defence
• Supervisors: prof. J. van Olmen, prof. E. Wouters, dr. S. Van Belle and prof. W. Van Damme

ABSTRACT

Worldwide, chronic non-communicable diseases (NCDs) are on the rise. Health systems need to transform to meet the complex care needs of persons with diabetes and cardiovascular conditions. Rather than being disease-focused and acute-oriented, health systems require emphasis on the promotion of a multidisciplinary approach and the provision of long-term care, over a continuum of health services ranging from health promotion and disease prevention to screening, diagnosis, treatment, disease management and control, to rehabilitation and palliative care. This integration of care, i.e. across the life course of the person with a chronic care need and across disciplines or sectors (e.g. commercial, political, financial, medical, social etc.), medical professional groups and specialisations (e.g. nurses, dieticians, general practitioners and specialists), levels (of care, but also of micro/meso/macro-context), requires multi-stakeholder engagement, e.g. via policy dialogues, and policy coordination and planning, e.g. via strategic roadmaps, within the context of integrated, collaborative governance and policy-making.

Strides have been made internationally and across nation states in the development implementation of integrated care initiatives, yet policy and system change to support the implementation and scale-up of integrated care for chronic diseases remains complex and challenging. Scaling up pertains to those efforts that increase the impact of health interventions for the benefit of more people, whilst fostering sustainable policies and programmes. In this thesis, we conceptualise scale-up as a multi-dimensional approach consisting of efforts to (1) increase population coverage, (2) expand or diversify what is included in the integrated care service package, and/or (3) institutionalise integrated care into health system services. In other words, scale up entails implementation processes at wider, deeper, and/or system scale.

The aim of this thesis is to understand the scale-up of integrated care in diverse health systems. The role of policy dialogues, stakeholders, scale-up roadmap development and implementation and contextual processes pose central elements in this quest. We draw on scale-up efforts from a resource-constrained health system in a lower-middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly-funded, highly privatised healthcare health system in a high-income country (Belgium). Complexity and systems thinking, as well as realist evaluation and implementation science offer interesting approaches and tools to study scaling. They each offer relevant perspectives on structures, agency, mechanisms, and processes to scale-up. These are aligned with the following objectives: (1) to examine how stakeholders can affect (support or block) integrated care policies, minding their power, interest and position; (2) to evaluate the process of how country-specific roadmaps are developed and implemented and reflect on how differing contexts can influence the implementation process of the scale-up roadmap-strategies; (3) to identify key underlying mechanisms which help to unravel the role of policy dialogues and evidence-based roadmaps in the scale-up process of integrated care from a realist perspective, whilst using political theory; (4) to assess contextual barriers and facilitators to the scale-up of integrated care; and (5) to generate lessons and recommendations on the role of policy dialogues and roadmaps in the scale-up of integrated care.

In chapters 3 to 9, our findings are presented, which offer varying analytical lenses to study scale-up. Chapter 3 (agency perspective) examines the policy process and the influence of stakeholders on three IC policies of the last decade in Belgium. This study shows that Belgium’s fragmented political structure itself clashes with the IC paradigm. The political fragmentation contributes to the abundance of inconsistent pilots emerging at both central and decentralised levels and to poor policy implementation, adaptation, and evaluation. All of this stands in the way of change towards more coordinated action. Chapter 4 (processes perspective) proposes process evaluation methods, whilst combining implementation science and scale-up theories in a joint evaluation framework. The framework entails early and mid-stage implementation outcomes, (late stage) scale-up outcomes and predominantly qualitative evaluation tools, which assess how stakeholders perceive the scale-up implementation process and are intended to support empirical scale-up research. Chapter 5 (mechanisms perspective) theorises on the use of policy dialogues to build a roadmap for scale-up of IC. Drawing from the multiple streams model (MSM), a political science theory, it develops an initial programme theory (IPT) on the scale-up process for IC. The IPT describes how and why an IC scale-up roadmap developed in policy dialogues is expected to work, hypothesizing that roadmap success (i.e. scale-up) occurs when there is convergence of (and agency within) the problem, solution, process, politics, and programme streams. Chapter 6 (structures perspective) entails a qualitative multi-case study on health system barriers and facilitators to the scale-up of IC in Cambodia, Slovenia, and Belgium. Common barriers to scaling up IC relate to: inadequate governance and leadership; health workforce capacity; health financing system; and fragmented health information systems. In Cambodia, access to NCD services and medicine present important challenges. In Slovenia, IC scale-up is facilitated by its strong governance and public health service model, but health workforce shortages risk progress. In Belgium, the fragmented multi-level governance structure and predominant fee-for-service provider payment are important issues. Across all the country cases, task shifting was seen as an important opportunity. Chapter 7 (processes perspective) entails the Belgian process evaluation. Scale-up of complex interventions, including the organisation of policy dialogues and the development and implementation of a strategic scale-up roadmap, demanded a collaborative, networking approach to build trust and buy-in. Such approach was deemed suitable given the fragmented, multi-level health governance system that typifies the Belgian health system. Chapter 8 (processes perspective) offers cross-country learnings on roadmaps for scaling up integrated care in Belgium, Slovenia, and Cambodia. Similar scale-up strategies were identified, including task-shifting; strengthening monitoring and evaluation; and creating an enabling environment for ICP implementation. Boundary spanning skills were another key commonality in every country change (implementation) team. Differences across country settings related to the scope and format of the roadmap; the scale-up dimensions given priority to and the mandate of the change team. A conceptual spiral model was developed showcasing overarching strategies as pre-requisites for scale-up.

The findings in this thesis contain key learnings on policy dialogues, roadmaps and scale-up. In chapter 9 and 10, we knit together these four perspectives on agency, processes, mechanisms, and structures and discuss and conclude that they are relevant to advance scale-up science. Our findings showed how scaling IC for chronic diseases requires (a) agency of key actors, such as boundary spanners, implementers, decision-makers, and political leaders; (b) its processes facilitated by policy dialogues (i.e. collaborative governance) and strategic roadmaps (i.e. policy coordination tools); (c) its processes to trigger underlying mechanisms, such as trust, engagement, knowledge mobilisation, political support and commitment; (d) its approaches and strategies to address and tackle system constraints (structures), which demands in-depth analysis using complex adaptive systems theory.

The wicked problems addressed in this thesis – NCDs, integrated care, effective policy implementation, and scaling up – highlight the inherent complexity, ambiguity, uncertainty, and power dynamics involved in addressing such society-wide challenges, emphasizing the need for collaborative, adaptive approaches that acknowledge diverse perspectives and meaningfully engage stakeholders in the problem-solving process. Considering change teams’ positionality and mandate and developing boundary spanning skills are crucial. Both policy and (realist or theory-driven) implementation research are needed to study and close the gap between science and politics to scale-up.

Nicolaas Martens

• 14 January 2025
• Time: 4:30 PM - 6:30 PM
• Venue: Campus Drie Eiken - Gebouw Q - D.Q.002 Promotiezaal
• PhD defence
• Supervisors: prof.3 B. Van Rompaey and prof. R. van der Mast

Katrien Danhieux

• 9 January 2025
• Time: 6 PM - 8 PM
• Venue: Campus Drie Eiken - Gebouw Q - D.Q.002 Promotiezaal
• PhD defence
• Supervisors: prof. J. van Olmen, prof. E. Wouters and em.prof. R. Remmen

Hosna Ghaderi

• 7 January 2025
• Time: 10 AM - 12 PM
• Venue: Campus Drie Eiken - Building S - D.S.1​
• PhD defence
• Supervisors: prof. J. Rozema, prof. C. Koppen, prof. M. Pierscionek 

Arezoo Farzanfar

• 7 January 2025
• Time: 2 PM - 4 PM
• Venue: Campus Drie Eiken - Building S - D.S.1​
• PhD defence
• Supervisors: prof. J. Rozema, prof. C. Koppen, prof. B. Pierscionek 

Nicolaas Martens

• 6 January 2025
• Time: 5 PM - 7 PM
• Venue: Campus Drie Eiken - Gebouw Q - D.Q.002 Promotiezaal or online​
• PhD defence
• Supervisors: em.prof. G. Dom and prof. M. Destoop