Heal h policy 141 (2024) 104997
A ailable online 17 Janua y 2024
0168-8510/© 2024 The Au ho (s). Published by Else ie B.V. This is an open access a icle unde he CC BY license (h p://c ea i ecommons.o g/licenses/by/4.0/).
Theo ies, models and amewo ks o heal h sys ems in eg a ion. A
scoping e iew
Celia Pique -Ma inez
a
,
*
, Amaia U ionagüena
b
, Shalom I. Ben imoj
a
, Bego˜
na Cal o
b
,
Sa ah Dineen-G i in
c
, Vic o ia Ga cia-Ca denas
a
, Fe nando Fe nandez-Llimos
d
,
Fe nando Ma inez-Ma inez
a
, Miguel Angel Gas elu u ia
a
,
b
a
Pha maceu ical Ca e Resea ch G oup, Facul y o Pha macy, Uni e si y o G anada, Campus de Ca uja s/n, G anada 18071, Spain
b
Pha macy P ac ice Resea ch G oup, Facul y o Pha macy, Uni e si y o he Basque Coun y, UPV/EHU, Vi o ia-Gas eiz, Spain
c
College o Heal h, Medicine and Wellbeing, School o Biomedical Sciences and Pha macy, The Uni e si y o Newcas le, Newcas le, Aus alia
d
Cen e o Heal h Technology and Se ices Resea ch (CINTESIS), Labo a o y o Pha macology, Depa men o D ug Sciences, Facul y o Pha macy, Uni e si y o Po o,
Po o, Po ugal
1. In oduc ion
1.1. Cu en landscape
Heal h sys ems a e acing inc easing p essu es due o se e al ac o s
such as he COVID-19 pandemic and ising heal h and social ca e de-
mands. Policy make s, esea che s, heal h manage s, and p ac i ione s
a e de eloping a ange o solu ions o add ess hese inc easing p essu es
on heal h sys em sus ainabili y, wi h he aim o a oiding agmen a ion
o duplica ion o se ices, and main aining a ocus on quali y, alue-
based ca e [1,2].
I has been sugges ed ha heal h sys ems mus e ol e as e and
e icien ly o be e mee exis ing and eme ging needs [3]. Heal h sys-
ems a e complex o ganiza ions cha ac e ized as “...a se o unc ions
ha gene ally include leade ship and go e nance, inancing, planning,
commodi ies, wo k o ce, se ice deli e y and in o ma ion sys ems wi h
he ul ima e goal o imp o e heal h ou comes” [4], wi h “a collec ion o
in e ac ing pa s ha unc ion o achie e a sha ed aim” [5] and
“encompass mul iple sec o s, o ganiza ions, and p o essionals in ol ed
in he deli e y o heal h ca e se ices” [6].
1.2. Unde s anding heal h sys em in eg a ion: in e na ional challenges
In e na ionally, heal h sys em in eg a ion is being u ilized as one o
he main s a egies o inc ease heal h sys em e iciency [7]. In eg a ion
o sys ems aims o de elop common isions, ocus esou ces, se ices
and a oidance o wo king in silos [7,8]. Heal h sys ems in coun ies such
as he Uni ed Kingdom [9], Uni ed S a ed [7] and Aus alia [10] a e
inc easingly becoming in eg a ed. In e es ingly, in hese coun ies,
pa icula emphasis is being gi en o he in eg a ion o p ima y heal h
ca e [11,12], inno a ion o new models o ca e [13], and emune a ion
s uc u es [14]. Despi e his end, many o he a emp s o in eg a e
heal h sys ems, se ices, and p og ams ha e been challenging, high-
ligh ing he complexi y o in eg a ion p ocesses o policy make s, e-
sea che s, heal h manage s and p ac i ione s [15,16].
This complexi y may be due o he lack o a clea and consis en
de ini ion, and associa ed implemen a ion s a egies o heal h sys em
in eg a ion, despi e he concep o in eg a ion gaining popula i y since
he 1990s [17]. The e m “in eg a ion” has been used in e changeably
wi h “in eg a ed ca e” and o he e ms such as “in eg a ed deli e y
sys ems”, “sys ems in eg a ion”, “in e disciplina y communica ion” and
“pa ien ca e eams” [18]. While in eg a ion is p ima ily di ec ed o
in eg a ing heal hca e sys ems, in eg a ed ca e p edominan ly ocusses
on pa ien ca e [19,20].
Some au ho s sugges ha he lack o ag eemen on de ining in e-
g a ion, combined wi h a pauci y o li e a u e on in eg a ed heal h
sys ems, has made i di icul o make p og ess in de eloping in eg a ion
science [19,21,22]. Howe e , a common de ini ion o heal h sys em
in eg a ion is “ he coo dina ion o heal h se ices and he collabo a ion
amongs p o ide o ganiza ions o es ablish an e ec i e heal h sys em”
[21,23]. As sugges ed by Sho ell e al. [24], in eg a ion may no be
iewed as an end goal, bu a he a p ocess o achie e o he ou comes,
such as in eg a ed ca e o imp o ed ma ke pe o mance o he sys em
and ul ima ely, a way o enhance heal h ou comes.
Since 2013, he e’s been a no iceable gap in li e a u e ega ding
heo ies, models, and amewo ks o heal h sys em in eg a ion [6].
While he E ans s udy [6] o e ed a b oad o e iew o in eg a ion
s a egies, wi h an emphasis on he e olu ion om ins i u ional o
communi y- ocused ca e, his s udy no only upda es hei indings bu
also analyzes he heo ies, models and amewo ks o iden i y hei
* Co esponding au ho .
E-mail add ess: [email p o ec ed] (C. Pique -Ma inez).
Con en s lis s a ailable a ScienceDi ec
Heal h policy
jou nal homepage: www.else ie .com/loca e/heal hpol
h ps://doi.o g/10.1016/j.heal hpol.2024.104997
Recei ed 29 May 2023; Recei ed in e ised o m 23 Decembe 2023; Accep ed 15 Janua y 2024
Heal h policy 141 (2024) 104997
2
a ious componen s. B eaking down heal hca e in eg a ion in o i s key
componen s may acili a e he de elopmen o mo e e ec i e s a egies,
as well as being able o e alua e he impac o a ious componen s o
heal hca e in eg a ion in e en ions.
1.3. Objec i e
The objec i e o his scoping e iew is o p o ide a summa y o
li e a u e ha iden i ies heo ies, models, o amewo ks used in heal h
sys ems in eg a ion. The speci ic objec i es we e o:
1. Iden i y and ca alog he heo ies, models, o amewo ks employed
in heal h sys em in eg a ion.
2. Analyze he common and dis inguishing componen s in hese he-
o ies, models, o amewo ks.
The ul ima e objec i e was o enhance he unde s anding o he
componen s o acili a e in o med selec ion and adap a ion by policy-
make s, p ac i ione s, and esea che s o aid he de elopmen o e ec-
i e s a egies and decisions ailo ed o speci ic con ex s.
2. Me hods
A sys ema ic scoping e iew o s udies epo ing heo ies, models o
amewo ks o heal h sys ems in eg a ion was pe o med using he JBI
guidance as ecommended by Coch ane [25]. The e iew is epo ed
ollowing he PRISMA guideline o scoping e iews [26]. A quali a i e
con en analysis o he selec ed publica ions was pe o med using an
amended me hodology desc ibed by Le ac [27].
2.1. Li e a u e sea ch
A comp ehensi e e iew by E ans e al. [6] om 1985 o 2013,
epo ing he main s a egies in heal h sys em in eg a ion h ough a
con en model analysis, was used as he s a ing poin o iden i y he-
o ies, models o amewo ks applied in heal h. A sea ch was pe o med
in i e da abases including Medline, Scopus, PsycIn o, Coch ane lib a y
and Web o Science be ween Janua y 2013 and Ap il 2023. Re e ence
lis s o he included a icles we e e iewed o iden i y u he ele an
a icles. The selec ed sea ch e ms we e simila o hose applied by
E ans e al. [6].
The sea ch s a egy in PubMed, which includes Medline and PubMed
Cen al da abases, was: (in eg a ed deli e y sys em” OR “o ganized
deli e y sys em”) AND (“sys ems in eg a ion”) AND (“in eg a ed heal h
ca e” OR “in eg a ed se ices” OR “in eg a ed sys em OR in eg a ed
deli e y”). The sea ch s a egies used o o he da abased a e in Ap-
pendix 1. The e ms heo ies, models and amewo ks we e no used in
he sea ch s a egy as in he p elimina y wo k up in de eloping he
sea ch s a egy i was ound ha hese limi ed he sea ch.
2.2. Eligibili y c i e ia
A icles we e included i hey desc ibed a heo y, model, o ame-
wo k o heal h sys em in eg a ion. A icles we e excluded i hey
desc ibed: (1) in eg a ion o speci ic p og ams o se ices o di e en
popula ions g oups; (2) case s udies (3) models o in eg a ed ca e; (4)
di e en ypes o heal h ca e o ganiza ions; and (5) he ypes o in e-
g a ion bu no inco po a ed hem in o a heo y, model o amewo k.
Nilsen’s classi ica ion o heo ies, models, and amewo ks was used
as a guide o his e iew [28] and is summa ized as ollows:
•A heo y is a sys em o analy ical ules o p oposi ions in ended o
o ganize ou obse a ions, unde s andings, and wo ld explana ions.
Theo ies ocus on he ela ionships o connec ions be ween
a iables.
•A model is an in en ional simpli ica ion o a phenomena o a
pa icula ea u e o a phenomenon. Models do no ha e o be pe ec
ep esen a ions o eali y o be use ul. Models a e heo ies wi h a
mo e na owly de ined scope o explana ion; whe eas a heo y is
bo h explana o y and desc ip i e, a model is desc ip i e.
•A amewo k is a s uc u e, o e iew, ou line, o plan made up o
nume ous desc ip i e ca ego ies, such as elemen s, componen s o
a iables, and he ela ionships ha a e supposed o explain a phe-
nomenon. F amewo ks do no gi e explana ions; hey jus desc ibe
empi ical ac s by pu ing hem in o a p ede e mined se o
ca ego ies.
In essence, a heo y would be he mos de eloped and complex o m
o explain how and why ce ain in e ac ions lead o ce ain ou comes. A
model p o ides a desc ip ion less de eloped bu mo e elabo a e han a
amewo k, which is a s aigh o wa d ep esen a ion o he di e en
elemen s o componen s.
2.3. Da a ex ac ion and analysis
One au ho (CP) e iewed i les and abs ac s and was o e inclusi e.
I any doub s a ose a second au ho (SB) was consul ed. The selec ed
a icles we e econside ed o inclusion applying he inclusion and
exclusion c i e ia in a ull- ex e iew. Any unce ain y ela ed o he
pape selec ion was esol ed h ough discussions be ween wo au ho s
(CP and SB) and, when consensus could no be eached a hi d au ho
(MAG) was consul ed. A quali a i e con en analysis o he included
s udies was applied o ex ac he da a using he me hodology desc ibed
by Le ac [27] which was based on he A ksey and O’Malley [29]
amewo k. This esea ch used he me hodology [27] consis ing o six
s ages: Iden i ying he Resea ch Ques ion, Sea ch S a egy, S udy Se-
lec ion, Cha ing he Da a, Colla ing, Summa izing, and Repo ing he
Resul s and Consul a ion. These six s eps we e ollowed in he esea ch
p ocess o his li e a u e e iew. Da a we e coded using a deduc i e and
desc ip i e me hod. The analysis was documen ed using Mic oso Wo d
and Excel 2016.
3. Resul s
3.1. Cha ac e is ics o included s udies
The li e a u e sea ch p oduced 5584 eco ds wi h 4094 eco ds
emaining a e emo ing duplica es. The sc eening by i le and abs ac
yielded 424 eco ds o ull- ex eligibili y, o which 36 we e inally
included in he da a ex ac ion. (See PRISMA diag am (Fig. 1)).
3.2. Componen s o he heo ies, models o amewo ks o heal h sys em
in eg a ion
O e all, wo heo ies (Table 1), i een models (Table 2) and eigh
amewo ks (Table 3) we e iden i ied om he included s udies. De ails
o he iden i ied heo ies, models and amewo ks a e p o ided in Ap-
pendix 2.
Th ough quali a i e con en analysis aimed a iden i ying ends,
pa e ns, and hemes in he li e a u e, ele en componen s eme ged, as
shown in Fig. 2. They a e desc ibed in o de o equency, below.
S akeholde s’ Managemen (n =22) was he mos equen ly
men ioned componen (Fig. 2) and e e s o he s a egic engagemen
and alignmen o all pa ies in ol ed in heal h ca e. I emphasizes he
impo ance o s ong ela ionships among heal h p o ide s, o ganiza-
ional membe s, and decision-make s. This componen highligh s he
i al ole s akeholde s ha e in guiding, suppo ing, and implemen ing
changes o achie e success ul heal h sys em in eg a ion.
Adequa e Funding (n =19) speaks o he s a egic alloca ion and
managemen o inancial asse s o d i e heal h in eg a ion. I en ails
sou cing unds om a ied channels, bo h public and p i a e, and
C. Pique -Ma inez e al.
Heal h policy 141 (2024) 104997
3
le e aging a combina ion o mone a y and non-mone a y incen i es o
s ee heal h sys em in eg a ion endea o s e ec i ely.
Technological connec i i y (n =19) is abou he c ea ion and
e ec i e use o sha ed echnological pla o ms. These pla o ms ensu e
consis en and e icien sha ing o i al in o ma ion, anging om
medical eco ds o clinical da a, p omo ing be e communica ion and a
s eamlined deli e y o se ices.
Roles (n =18) emphasizes ensu ing ha e e y s akeholde in he
heal h sys em unde s ands hei speci ic unc ions and esponsibili ies.
This cla i y ensu es a ha monized app oach o ca e, wi h e e yone
aligned in hei oles du ing he in eg a ion jou ney.
Go e nance (n =18) in ol es c a ing and implemen ing an o ga-
niza ional bluep in ha consis s o go e ning boa ds, leade ship as-
semblies, and s ee ing commi ees. Such s uc u es a e impe a i e o
gua an eeing smoo h coo dina ion, policy upda es, and se ing he
s a egic cou se in in eg a ed heal h en i onmen s.
Communica ion (n =18) en ails sys ema ic and s a egic in e ac ions
wi hin he heal h sys em amewo k. Wi h egula engagemen s, e i-
cien da a ansmission, and s uc u ed mee ings, i aims o p omo e
cohesi e eam-o ien ed app oach.
Sha ed Vision, Values, Goals, and T us (n =18) highligh s he
impo ance o consensus and alignmen among all s akeholde s. This
in ol es se ing collec i e goals, upholding ag eed-upon e hical alues,
and os e ing an en i onmen o us , which is o en en iched by p e-
ious collabo a i e endea o s and pa ne ships.
Con ex (n =16) ecognizes he need o adap abili y and un-
de sco es he impo ance o ailo ing heal h in eg a ion s a egies o
local condi ions, he ma ke dynamics o speci ic egional ac o s, such
as ins i u ional con ex , o ganiza ional s uc u e, demog aphic, eco-
nomic, poli ical, legal, ecological, socio-cul u al, and echnological
Fig. 1. PRISMA lowcha o s udy selec ion p ocess.
Table 1
In eg a ion componen s a ge ed by heal h sys em in eg a ion heo ies.
Heal h
Sys ems
In eg a ion
Theo y
S akeholde
managemen
Adequa e
unding
Technological
connec i i y
Roles Go e nance Communica ion Sha ed
ision,
alues
and goals
Con ex Cul u e Communi y
engagemen
Co-
loca ion
Complex
Adap i e
Sys em
[30–36,15]
X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X X
In eg a ion
deg ee [37,
38]
✓ ✓ ✓ X X ✓ ✓ ✓ ✓ ✓ ✓
Summa y: (✓) componen p esen ; (X) componen absen .
C. Pique -Ma inez e al.
Heal h policy 141 (2024) 104997
4
ac o s, in he en i onmen whe e in eg a ion will ake place. I ’s abou
ensu ing ele ance and esponsi eness.
Cul u e (n =15) ocuses on cul i a ing a sha ed unde s anding o
g oup dynamics, s o ies, and alues. Leade s and manage s play a
pi o al ole, ensu ing ha he en i onmen champions collabo a ion
and places emphasis on no ma i e uni y.
Communi y Engagemen (n =14) is abou p oac i ely d awing he
b oade communi y in o he in eg a ion p ocess. By aligning wi h he
needs, p e e ences, and alues o pa ien s and amilies, his componen
ensu es he in eg a ion echoes he p inciples o people-cen ic ca e.
Co-loca ion (n =10) was he leas men ioned componen and i
emphasizes he impo ance o placing heal h se ice p o ide s in sha ed
o nea by loca ions.
4. Discussion
4.1. Summa y o indings and con ibu ion o he li e a u e
This e iew p o ides an up o-da e mapping o he heo ies, models
and amewo ks a ailable o heal h sys ems in eg a ion. Key compo-
nen s a e iden i ied o assis policy make s, esea che s, and o he
s akeholde s in selec ing he mos sui able o mix o heo ies, models o
amewo ks o mee hei speci ic objec i es.
The li e a u e e ealed di e ences in he numbe o heo ies
(Table 1), models (Table 2), and amewo ks (Table 3). In addi ion o he
wo in eg a ion heo ies iden i ied in his e iew, some in eg a ion
models applied heo ies de i ed om o he disciplines such as economic
o o ganiza ional heo ies i.e.: Open sys ems heo y (LOPSI model) [2],
collabo a i e capi al (Ou come Map) [46] and Ins i u ional economic heo y
(Con inuum o in eg a ion) [18]. These heo ies we e no included in his
scoping e iew since hey we e no speci ic o in eg a ion.
Addi ional e minologies, including ne wo k, mapping o oolki ,
we e used by se e al au ho s o desc ibe heo ies, models and ame-
wo ks o heal h sys ems in eg a ion [24,39,46]. Fo consis ency o
analysis, hese we e eca ego ized as heo ies, models o amewo ks
acco ding o he de ini ions by Nilsen [28] p e iously desc ibed. As
Nilsen P. s a es, he e is a signi ican deg ee o o e lap be ween hese
ca ego ies.
Table 2
In eg a ion componen s a ge ed by heal h sys em in eg a ion models.
Heal h Sys ems
In eg a ion Model
S akeholde
managemen
Adequa e
unding
Technological
connec i i y
Roles Go e nance Communica ion Sha ed
ision,
alues
and
goals
Con ex Cul u e Communi y
engagemen
Co-
loca ion
Model o an
In eg a ed Heal h
Sys em [21]
✓ ✓ X ✓ ✓ X X ✓ X X X
Ne wo k In eg a ion
[39]
X X X ✓ X X ✓ X X X X
The Landscape o
Physician–Sys em
In eg a ion Model
[40]
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
In eg a ion o
Communi y
Heal h and
P e en ion in o
Communi y-
based P ima y
Ca e [41]
✓ ✓ ✓ ✓ ✓ ✓ ✓ X ✓ ✓ X
The McKinsey 7S
Model [42,43]
✓ X ✓ ✓ ✓ ✓ ✓ X ✓ ✓ ✓
Concep ual Model
o In eg a ion
Types [44]
✓ X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
In eg a ed P ima y
Ca e [16]
✓ ✓ X ✓ X ✓ X X ✓ X ✓
P o ide -based
Concep ual Model
[45]
✓ X X X X X X X X X ✓
Con inuum o
In eg a ion [18]
X ✓ ✓ ✓ ✓ ✓ ✓ ✓ X X X
Ou come Map [46] ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Model o In eg a ed
Se ice Deli e y
[47]
✓ X ✓ ✓ ✓ ✓ ✓ ✓ X X X
The 3C’s Model
[40]
✓ ✓ ✓ ✓ ✓ ✓ ✓ X ✓ ✓ X
The in eg a ion
oolki and he
Building Blocks o
In eg a ion [24]
✓ ✓ ✓ ✓ ✓ ✓ X X X ✓ X
The Embedded CAS
Concep ual Model
[48]
✓ X ✓ X ✓ ✓ X ✓ ✓ X X
An in eg a i e
model o
physician hospi al
alignmen [49]
✓ ✓ ✓ ✓ X X X X X X X
Summa y: (✓) componen p esen ; (X) componen absen .
C. Pique -Ma inez e al.
Heal h policy 141 (2024) 104997
5
4.2. Simila i ies and di e ences in heal h sys em in eg a ion heo ies
In e es ingly, only wo heo ies we e iden i ied in his e iew
(Table 1). The In eg a ion Deg ee heo y [37,38], sugges s ha heal h
in eg a ion is a g adual p ocess ha in ol es di e en le els o in e-
g a ion, wi h each le el building on he p e ious one. The heo y p o-
poses ha heal h in eg a ion can be measu ed by he deg ee o
in eg a ion, which is de e mined by he ex en o in e dependence and
coope a ion among o ganiza ions. I also sugges s ha he e a e
di e en ypes o in eg a ion, such as unc ional, s uc u al, and ope -
a ional, each o which se es a speci ic pu pose.
Compa a i ely, he Complex Adap i e Sys em (CAS) heo y [35],
iews heal h in eg a ion as a complex and adap i e p ocess ha is
in luenced by a ious ac o s such as he cha ac e is ics o he o gani-
za ions in ol ed, he ex e nal en i onmen , and he in e ac ions among
o ganiza ions. The heo y sugges s ha heal h in eg a ion is nonlinea
and is subjec o cons an change, as new s uc u es and pa e ns o
beha iou eme ge.
Bo h heo ies sugges ha heal h in eg a ion is complex and in lu-
enced by a ious ac o s, such as he cha ac e is ics o he o ganiza ions
in ol ed and he ex e nal en i onmen . Bo h heo ies sugges ha
heal h in eg a ion in ol es coope a ion and in e dependence among
o ganiza ions. Addi ionally, bo h emphasize communica ion and ech-
nological connec i i y among o ganiza ions o success ul heal h in e-
g a ion. Howe e , in he In eg a ion Deg ee heo y, communica ion and
Table 3
In eg a ion componen s a ge ed by heal h sys em in eg a ion amewo ks.
Heal h Sys ems
In eg a ion
F amewo k
S akeholde
managemen
Adequa e
unding
Technological
connec i i y
Roles Go e nance Communica ion Sha ed
ision,
alues
and
goals
Con ex Cul u e Communi y
engagemen
Co-
loca ion
Analy ical
F amewo k o
In eg a ion [50]
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X
Concep ual
F amewo k:
Fi e Heal h
Ca e Ac i i ies
ha Facili a es
In eg a ion [51]
✓ ✓ X X X X ✓ ✓ X ✓ X
The Fou Domain
In eg a ed
Heal h
F amewo k
[52]
✓ ✓ X X X X X ✓ X ✓ X
Theo e ical
F amewo k o
Di e en Fo ms
o In eg a ion
[53,54]
✓ ✓ ✓ ✓ ✓ ✓ ✓ X X X ✓
Moni o ing and
E alua ion
F amewo k o
In eg a ion [55]
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X
Concep ual
F amewo k o
Analysing
In eg a ion o
Ta ge ed Heal h
In e en ions
in o Heal h
Sys ems [4]
✓ ✓ ✓ X ✓ X ✓ ✓ ✓ ✓ X
F amewo k o an
In eg a ed
Sys em
Sco eca d [56]
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X ✓
F amewo k o
examining
in eg a ion [17]
✓ ✓ ✓ X ✓ ✓ ✓ ✓ ✓ ✓ ✓
Summa y: (✓) componen p esen ; (X) componen absen .
Fig. 2. Bubble plo s showing he dis ibu ion o componen s o he heo ies,
models o amewo ks o heal h sys em in eg a ion. Foo no e: Each bubble in
he igu e ep esen s a key componen o heo ies, models o amewo ks o
heal h sys em in eg a ion. The size o he bubble is p opo ional o he numbe
o imes he componen was iden i ied in s udies.
C. Pique -Ma inez e al.
Heal h policy 141 (2024) 104997
6
echnological connec i i y is sugges ed o be impo an o achie ing
di e en le els o in eg a ion, while in he Complex Adap i e Sys em
(CAS) heo y [36], communica ion and echnological connec i i y a e
impo an o acili a ing he adap i e p ocess, o c ea e mo e apid
esponses o new si ua ions and challenges and he eme gence o new
s uc u es and pa e ns o beha iou [32,35].
In eg a ion deg ee heo y may be easie o adap o each heal h sys em
in eg a ion con ex o speci ic p og ams, as sugges ed by McVica [37].
Howe e , CAS heo y emphasizes he impo ance o all s akeholde s in
he p ocess, he analysis o he p ees ablished hie a chy and he ele-
ance o adap abili y o u u e e en s.
4.3. Simila i ies and di e ences in heal h sys em in eg a ion models
Mos o he models iden i ied (n =15) (Table 2) emphasized he
impo ance o coope a ion and in e dependence among o ganiza ions o
achie e e ec i e heal h in eg a ion. Some di e ences be ween models
included he speci ic ocus o goal o he model, he in ensi y o in e-
g a ion i aims o achie e [40], he ype o in eg a ion i emphasizes
(such as unc ional, s uc u al, o ope a ional) [57], he speci ic com-
ponen s o elemen s i includes, he ype o o ganiza ions o s ake-
holde s i a ge s, he le el o adap abili y o lexibili y i allows o , he
da a o me ics used o measu e success ul in eg a ion, he unde pinning
heo e ical o concep ual amewo k, and he le el o complexi y o
simplici y o he model. Fo example, Ne wo k in eg a ion [39] empha-
sizes he ole o ne wo ks in acili a ing communica ion and coope a ion
among o ganiza ions. In con as , The Landscape o Physician–Sys em
In eg a ion (LOPSI) model [2] co e s all componen s bu was highly
ocused on he in eg a ion o physicians in o he heal hca e sys em,
which may no be app op ia e o all o ganiza ions o goals. The 3C’s
Model [40] emphasizes he in eg a ion, coo dina ion, and con inui y o
ca e, p o iding a comp ehensi e app oach o heal h sys em in eg a ion.
4.4. Simila i ies and di e ences in heal h sys em in eg a ion amewo ks
Eigh amewo ks we e iden i ied in his e iew which appea o
ha e simila i ies (Table 3). All he iden i ied amewo ks ocus on
analyzing and e alua ing di e en aspec s o in eg a ion in heal h sys-
ems, acili a ing in eg a ion wi hin heal h sys ems, assessing pe o -
mance, and unde s anding he di e en o ms o in eg a ion in heal h
sys ems. Howe e , hey di e in hei speci ic elemen s, ac i i ies, do-
mains, and app oaches used o e alua e and analyze in eg a ion. Fo
example, The Analy ical F amewo k o In eg a ion [50] ocuses on
go e nance, inancing, se ice deli e y, human esou ces, and in o -
ma ion sys ems. Compa a i ely, he 5As amewo k ocuses on i e ac-
i i ies (Awa eness, adjus men , assis ance, alignmen , and ad ocacy)
[51] while he 4DIH amewo k [52] ocuses on ou domains o in e-
g a ion, such as he na u e o he p oblem, he s uc u e o he heal h
sys em, sys ems o ca e and global p io i ies. The Theo e ical F amewo k
o Di e en Fo ms o In eg a ion [53] p o ides a heo e ical unde s and-
ing, based on Axelsson and Biha i Axelsson [54], ou lining di e en
s a egies o be used in in eg a ion p ocesses. The M&E amewo k [55]
p o ides a s uc u e o moni o ing and e alua ing he p og ess and
impac o in eg a ion in heal h sys ems. This includes de ining heal h
challenges speci ic o he coun y, iden i ying c ucial poin s o con ac
o ca e, c ea ing logic models o ou line possible causal pa hways, and
enhancing he heal h in o ma ion sys em and da a u iliza ion.
4.5. Explo ing he key componen s o heo ies, models o amewo ks
used in heal h sys ems in eg a ion
All he componen s iden i ied may be applicable a a ying in ensi y
o all ac o s in he in eg a ion p ocess. Fo example, om a poli ician’s
pe spec i e when de eloping a policy, policy make s migh p io i ize
‘s akeholde managemen ’ and ‘adequa e unding’ due o he need o
poli ical suppo and iscal pu poses. Meanwhile, o an adminis a o ,
‘go e nance’, ‘communi y engagemen ’ and ‘ echnological connec i i y’
migh be mo e ele an due o o ganisa ional easons.
4.5.1. S akeholde managemen
Building ela ionships and inding ways o b ing oge he a ious
and di e en pe spec i es o c ea e a sha ed unde s anding among all
pa ies is o majo signi icance [46,51]. Se e al expe s [31,37] a gue
ha changes o he o ganiza ional s uc u e and managemen cul u e
may be necessa y o p omo e s akeholde pa icipa ion. Fo example,
Sho ell e al. [47] sugges s a shi owa ds a “new managemen cul u e”
which could in ol e c ea ing mo e decen alized and pa icipa o y
decision-making p ocesses, in addi ion o es ablishing clea lines o
communica ion and accoun abili y be ween di e en s akeholde s.
O he s a egies o p omo ing s akeholde pa icipa ion in heal h
in eg a ion sys ems may include incen i izing collabo a ion h ough
inancial o non- inancial ewa ds, p o iding aining and suppo o
e ec i e eamwo k and communica ion, and os e ing a sha ed sense o
mission and pu pose among s akeholde s. Ul ima ely, success o heal h
sys em in eg a ion appea s o depend on ac i e engagemen and
pa icipa ion o all s akeholde s, and ongoing e o s a e needed o
p omo e his collabo a ion and coope a ion.
4.5.2. Adequa e unding
E ec i e in eg a ion o heal h sys ems equi es changes in o gani-
za ional s uc u es and p ocesses and su icien inancial esou ces o
sus ainabili y. Inadequa e unding limi s he success o in eg a ion e -
o s, as o ganiza ions may no ha e he necessa y esou ces o suppo
new ac i i ies and oles. Se e al s udies emphasize he need o iden i-
ying he op imal egula ion and budge a y suppo o ully ealize he
alue o heal h sys em in eg a ion [31]. Va ious ypes and sou ces o
unding we e iden i ied in his e iew, including global hospi al bud-
ge s, pay- o -pe o mance, medical o se s o e en a combina ion o
mone a y and non-mone a y incen i es [32].
4.5.3. Technological connec i i y
Technological connec i i y plays a c ucial ole in he success o
heal h sys em in eg a ion. Di e en solu ions o esol e echnological
connec i i y we e ound, pa icula ly a common pla o m, echnology o
sys em [32,42,43] o sha e da a and in o ma ion. This was iden i ied o
imp o e clinical decision-making, educe e o s, imp o e pa ien ou -
comes, achie e ce ain y in in e p o essional eamwo k, acili a e
communica ion [32], imp o e se ice deli e y sys ema iza ion and
p edic abili y [56], p e en delays in ca e, a oid duplica ion o e o s,
and ensu e pa ien s ecei e he mos app op ia e and imely ca e.
4.5.4. Roles
Heal h sys em in eg a ion equi ed cla i y o oles [44,46] in he
majo i y o he heo ies, models and amewo ks ound in he li e a u e
(n =18). Heal h p o ide s equi e ole delinea ion [15,42] and an un-
de s anding o he ole o each p o ide , i.e., he es ablishmen o clea
esponsibili ies o p o ide s esponsible o he same pa ien ’s ca e.
Singe e al. [44] sugges ha de ining o oles and du ies may shi om
“li le app ecia ion o o he ’s ole” o “in-dep h unde s anding o o he s
oles” [16]. Howe e , he CAS heo y [32] sugges s ha oles should no
be s ic ly de ined because he compe encies equi ed o a ask belong
no o an indi idual agen bu o he coope a ion o he di e en agen s
and he ocus should be mo e on ag eed ac ions.
4.5.5. Go e nance
Se e al o he heo ies, models and amewo ks o heal h sys ems
in eg a ion p esen ed a go e nance o leade ship s uc u e wi h all
s akeholde s ep esen ed [50] o sus ain he p og ess o he in eg a ion
p ocess [42]. Fu he mo e, sha ed accoun abili y [46], and managing
“compe ing in e es s” we e also highligh ed as impo an o s ong
go e nance [50]. Sims e al. [58] highligh ed ha a sha ed mis-
sion/ ision, suppo i e ela ionships, us and e ec i e communica ion
C. Pique -Ma inez e al.
Heal h policy 141 (2024) 104997
7
a e equi ed o e ec i e go e nance. Managemen , go e nance, and
clinical p ac ice elemen s should be de eloped and aligned o ully
suppo in eg a ion e o s [17,24].
4.5.6. Communica ion
Communica ion was a cen al componen among heo ies, models
and amewo ks o his e iew. I was sugges ed ha e ec i e commu-
nica ion may ans o m in o less bu eauc acy and adminis a i e wo k
[24,47,48], inc ease e iciency [33,34], and in e p o essional enhanced
us , o a i e o a sha ed concep o eam-based ca e [16]. Many
di e en ways o p omo e communica ion we e sugges ed, such as
egula mee ings, join planning and decision-making, ace- o- ace in-
e ac ions, implemen ing sha ed pa ien elec onic heal h eco ds,
o mal communica ion p o ocols and p ac ices o in o mal con e sa-
ions [35,49,53].
4.5.7. Sha ed ision, alues and goals
O e all, he iden i ied heo ies, models and amewo ks highligh ed
he alue o a sha ed ision among heal h p o ide s a e equi ed o align
alues, goals and easons such as an imp o emen in heal h ou comes
[16], a educ ion in cos s [15], add ess heal h dispa i ies, enhance
quali y o li e, dec ease wai ime, and imp o e access o ca e [41]. I
was sugges ed ha consensus may be eached h ough ca e-planning
mee ings [50,53,54], and p og ams o policy decision make s [55] o
ensu e a clea unde s anding on he objec i es o he sys em [56].
4.5.8. Con ex
Indi idual coun ies ha e di e en economic, poli ical and business
[59] con ex s o legal condi ions ha impac heal h sys em in eg a ion
[21]. Fo ins ance, he economic landscape, poli ical p io i ies, and legal
amewo ks can shape he s a egies and ou comes o in eg a ion e o s
Singe e al. [44] sugges ha con ex can be unde s ood as in e nal and
ex e nal o ganiza ional cha ac e is ics, whe eas in e nal con ex is
ela ed o he size o he heal h sys em, numbe o p ac ice si es o
special y mix, whe eas ex e nal con ex is ela ed o he s uc u e o he
heal h ma ke , which also has an in luence on he in eg a ion p ocess
[45].
4.5.9. Cul u e
A need o including a componen on cul u al ans o ma ion in
heal h sys em in eg a ion was iden i ied in he heo ies, models and
amewo ks h ough he adop ion o no ms and wi h an unde s anding
o he en i onmen o wo k is ad oca ed [46]. I is shown ha he
adop ion o new ideas and echnologies a e impac ed by dominan
cul u al no ms and p inciples held by o ganiza ions in he in eg a ion
p ocess [4]. I is sugges ed ha o ganiza ions should cul i a e a lea ning
cul u e ha conside s bo h indi idual and g oup needs. O ganiza ional
na a i es play a ole in shaping cul u e, and pe sonal s o ies a e
impo an in building g oup solida i y and c ea ing a sha ed ision.
S o ies can be used o b ing oge he he mul iple p o essional iden i ies
wi hin an o ganiza ion in o a sha ed cul u al iden i y ha can d i e
imp o emen [30].
4.5.10. Communi y engagemen
Communi y engagemen is a c ucial aspec o heal h sys em in e-
g a ion as i in ol es he in ol emen o he popula ion and pa ien s in
he in eg a ion p ocess and he assessmen o hei heal h needs [4,55].
Di e en s a egies o p omo e communi y engagemen ha e been
iden i ied, such as communi y ou each, communi y mee ings, pa -
ne ships, ad iso y g oups, heal h li e acy and educa ion [41,54]. These
s a egies p o ide eedback and guidance o quali y imp o emen ,
communica ion be ween p o ide s and pa ien s, and alignmen o local
solu ions o local p oblems [40]. The in ol emen o he communi y, as
a whole, is signi ican because i helps o o e come limi ed awa eness
and unde s anding ac oss o ganiza ions and p o essionals [52]. Th ough
communi y engagemen , i is sugges ed ha heal h p o ide s can be e
unde s and he speci ic needs and p io i ies o he communi ies hey
se e [44,60]. Sha ing in o ma ion a he local le el os e s in eg a ion
and engagemen [36].
4.5.11. Co-loca ion
Co-loca ion was he leas men ioned componen o heal h sys em
in eg a ion and a he iden i ied as a “collabo a ion acili a o ” [37] o
imp o ed communica ion and in o ma ion exchange among eam
membe s. When indi iduals wo k in p oximi y, hey a e mo e likely o
engage in ace- o- ace communica ion and build ela ionships based on
us , sha ed pu pose, and mu ual unde s anding. This can help o b eak
down silos and imp o e coo dina ion and in eg a ion be ween di e en
heal h p o ide s and o ganiza ions [42]. Co-loca ion is also sugges ed o
acili a e he sha ing o esou ces and expe ise, allowing o mo e
e icien and e ec i e deli e y o ca e [44]. Howe e , o he au ho s [56]
a gue ha he e is no empi ical e idence o suppo he e ec i eness o
co-loca ion in he in eg a ion p ocess and ha he se ices could be
unc ioning no mally in indi idual acili ies, wi hou any ocus on
coo dina ing wi h o he loca ions. Face- o- ace con ac , egula mee -
ings and use o echnology may help o o e come his ba ie o sha ing
space o physical p oximi y.
4.6. Implica ions o u u e p ac ice, policy, and esea ch
This scoping e iew p o ides insigh s o esea che s, decision-
make s and poli ical leade s in designing in eg a ion s a egies ha
sui he speci ic cha ac e is ics o hei heal h sys ems. In eg a ion o
heal h o ganiza ions and p o essional g oups such as physicians [2],
nu ses [4,42], pha macis s [61], social wo ke s [51], adminis a i e
s a [16] and pa ien s [41,60], can lead o be e use o esou ces,
imp o ed heal h ou comes, and educed adminis a i e wo kload [17,
40]. While o ganiza ional and p ocess- ocused s a egies such as
go e nance, in o ma ion echnology, and da a a e impo an , hey alone
seem insu icien [30].
This e iew ound ha he e is no dominan heal h sys em in eg a-
ion heo y, model o amewo k sugges ing ha a one-size- i s-all so-
lu ion may be ine ec i e [62]. The ele en componen s iden i ied in
heo ies, models and amewo ks ha e di e en applicabili y and in-
ensi y o he h ee le els (i.e. mic o a a local p ac ice le el, meso a a
s a e le el, mac o a a na ional le el) o heal h sys em. ‘Adequa e
unding’, ‘s akeholde managemen ’ and ‘go e nance’ may apply o all
le els. ‘Roles’ and ‘co-loca ion’ a e pa icula ly mo e ele an o he
mic o le el. Howe e , wha is clea is ha i is c ucial o conside he
social and poli ical dimensions o heal h sys ems and in ol e heal hca e
p o ide s in he p ocess o p omo e a g ass- oo s p o essional mo e-
men , os e a commi men o a common pu pose, and build a us ed
ne wo k. The indings o his e iew highligh he need o u he
esea ch in o heal h sys em in eg a ion, pa icula ly in e ms o de el-
oping and e alua ing e ec i e heo ies, models and amewo ks.
4.7. Limi a ions
The e a e se e al limi a ions o his e iew. Fi s , he e is no ag ee-
men on a de ini ion o he e m "in eg a ion" in he li e a u e, and as
such no all s udies may ha e been iden i ied because o he sea ch
s a egy applied. Secondly, as he ocus o his e iew is on he published
scien i ic li e a u e, ele an in o ma ion in he g ey li e a u e may ha e
been omi ed. Addi ionally, al hough only one au ho (CP) e iewed
i les and abs ac s, and his acknowledged as a limi a ion, he e we e
many gene al discussions wi h o he au ho s (SB). Fu he mo e, while
he e iew iden i ied key componen s o in eg a ion, i did no del e
in o speci ic ba ie s and acili a o s in luencing he e ec i eness o
in eg a ion ac oss di e en se ings. The iden i ied heo ies, models, and
amewo ks we e no ho oughly ca ego ized based on he pa icula
heal h p o essionals in ol ed in he in eg a ion p ocess. Finally, his
s udy did no explo e me hods o quan i ying he in ensi y o deg ee o
C. Pique -Ma inez e al.
Heal h policy 141 (2024) 104997
8
in eg a ion and i s a ious componen s.
5. Conclusions
This e iew sugges s ha heal h sys em in eg a ion is a complex and
mul i ace ed p ocess ha equi es he managemen and pa icipa ion o
mul iple s akeholde s. The heo ies, models and amewo ks iden i ied
in his e iew may be used o de elop in eg a ed heal h sys ems ha
p o ide, amongs o he ou pu s, seamless ca e ac oss di e en p o ide s
and se ings, such as specialis ca e and p ima y ca e.
The iden i ica ion o 11 key componen s p o ides a use ul s a ing
poin o policymake s and p ac i ione s o unde s and he ac o s ha
a e essen ial o success ul in eg a ion. These componen s ha e a b oad
ange o po en ial applica ions, which can span he a ious le els
(mic o, meso, and mac o), geog aphic scopes (local, egional, and na-
ional), and o ganiza ional bounda ies (wi hin o ac oss o ganiza ions).
In addi ion, he ma u i y o heal h ca e sys ems may be an impo an
con ex ual issue o conside . They o e lexibili y and applicabili y o
di e se con ex s and se ings, enabling hei use ac oss a wide spec um
o heal hca e in eg a ion ini ia i es.
These componen s help unde s and, selec models, ini ia e in eg a-
ion, and implemen in eg a i e app oaches e ec i ely. They apply a
di e en s ages o in eg a ion, om planning o ongoing imp o emen .
Howe e , hey may ha e some applica ion in o he o ms ou side in e-
g a ion o heal h sys ems.
Fu he esea ch in o he applica ion o hese indings ha e he po-
en ial o heal h sys em in eg a ion which subsequen ly may lead o
imp o ing he o e all quali y o ca e and ou comes o pa ien s.
Funding
This esea ch did no ecei e any speci ic g an s o unding om
agencies in he public, comme cial, o no - o -p o i sec o s.
CRediT au ho ship con ibu ion s a emen
Celia Pique -Ma inez: Concep ualiza ion, Fo mal analysis, W i ing
– o iginal d a , W i ing – e iew & edi ing. Amaia U ionagüena:
Concep ualiza ion, W i ing – e iew & edi ing. Shalom I. Ben imoj:
Fo mal analysis, Supe ision, W i ing – o iginal d a , W i ing – e iew
& edi ing, Concep ualiza ion. Bego˜
na Cal o: W i ing – e iew & edi -
ing. Sa ah Dineen-G i in: W i ing – e iew & edi ing. Vic o ia Ga -
cia-Ca denas: W i ing – e iew & edi ing. Fe nando Fe nandez-
Llimos: W i ing – e iew & edi ing. Fe nando Ma inez-Ma inez:
Supe ision, W i ing – e iew & edi ing. Miguel Angel Gas elu u ia:
Supe ision, W i ing – e iew & edi ing.
Decla a ion o compe ing in e es
The au ho s epo no con lic o in e es .
Acknowledgemen s
We acknowledge he Uni e si y o G anada, Spain (UGR) o hei
suppo . This wo k is pa o Celia Pique -Ma inez’s PhD in Social
Pha macy.
Supplemen a y ma e ials
Supplemen a y ma e ial associa ed wi h his a icle can be ound, in
he online e sion, a doi:10.1016/j.heal hpol.2024.104997.
Re e ences
[1] Che new ME, Conway PH, F ak AB. T ans o ming medica e’s paymen sys ems:
p og ess shaped by he ACA: a na a i e e iew o A o dable Ca e Ac paymen
e o ms. Heal h A 2020;39:413–20. h ps://doi.o g/10.1377/
hl ha .2019.01410.
[2] Nguyen AM, Johnson CE, Wood SJ, Dowling WL. O ganiza ional ac o s a ec ing
success ul physician-sys em in eg a ion: a quali a i e s udy o Washing on S a e
heal h execu i es. Heal h Ca e Manag Re 2021;46:35–43. h ps://doi.o g/
10.1097/HMR.0000000000000238.
[3] Minde hou RN, Baks een MC, Numans ME, B uijnzeels MA, Vos HMM. E ec o
COVID-19 on heal h sys em in eg a ion in he Ne he lands: a mixed-me hods s udy.
J Am Coll Eme g Physicians Open 2021;2:1–10. h ps://doi.o g/10.1002/
emp2.12433.
[4] A un R, de Jongh T, Secci F, Ohi i K, Adeyi O. In eg a ion o a ge ed heal h
in e en ions in o heal h sys ems: a concep ual amewo k o analysis. Heal h
Policy Plan 2010;25:104–11. h ps://doi.o g/10.1093/heapol/czp055.
[5] Bo T., Williams S., Childe house P., Deakins E., Zealand N., Towill D. Squa ing he
ci cle o heal hca e supplies supplies 2014;28:247–65. 10.1108/JHOM-01-201
3-0014.
[6] E ans JM, Bake RG, Be a W. The e olu ion o in eg a ed heal h ca e s a egies. In:
Goes J., Sa age G.T., F iedman L., edi o s. Ad ances in heal h ca e managemen ,
15. Eme ald G oup Publishing Limi ed; 2013. p. 125–61. h ps://doi.o g/10.1108/
s1474-8231(2013)0000015011.
[7] Sandhu S, Sha ma A, Chole a R, Be ge JP. In eg a ed heal h and social ca e in he
Uni ed S a es: a decade o policy p og ess. In J In eg Ca e 2021;21:9. h ps://doi.
o g/10.5334/ijic.5687.
[8] Timmins N, Ham C. The ques o in eg a ed heal h and social ca e: a case s udy in
Can e bu y, New Zealand. Kings Fund; 2013. p. 64.
[9] C. Fulle . Nex s eps o in eg a ing p ima y ca e: Fulle S ock ake epo . NHS UK
2022:38. h ps://www.england.nhs.uk/wp-con en /uploads/2022/05/nex -s eps
- o -in eg a ing-p ima y-ca e- ulle -s ock ake- epo .pd (accessed Ap il 4, 2023).
[10] T ankle SA, Ushe wood T, Abbo P, Robe s M, C amp on M, Gi gis CM, e al.
In eg a ing heal h ca e in Aus alia: a quali a i e e alua ion. BMC Heal h Se Res
2019;19:954. h ps://doi.o g/10.1186/s12913-019-4780-z.
[11] Khan AI, Ha is JK, Ba nsley J, Wodchis W. Explo ing in a and in e o ganiza ional
in eg a ion e o s in ol ing he p ima y ca e sec o –a case s udy om On a io. In
J In eg Ca e 2022;22:1–17. h ps://doi.o g/10.5334/ijic.5541.
[12] Sulli an EE, B e on M, McKins y D, Phillips RS. COVID-19’s pe cei ed impac on
p ima y ca e in New England: a quali a i e s udy. J Am Boa d Fam Med 2022;35:
265–73. h ps://doi.o g/10.3122/jab m.2022.02.210317.
[13] Bu ns LR, Goldsmi h JC, Sen A. Ho izon al and e ical in eg a ion o physicians: a
ale o wo ails. In: Goes J., Sa age G.T., F iedman L., edi o s. Ad ances in heal h
ca e managemen , 15. Eme ald G oup Publishing Limi ed; 2013. p. 39–117.
[14] Domb owski SK, Bacci JL, Kla PM, Osbo ne M, Cas elli G, Bu ns A, e al. Key
ac o s o sus ainable in eg a ion o pha macis s in eam-based p ima y ca e
physician p ac ices. J Am Pha m Assoc 2019;59:439–48. h ps://doi.o g/10.1016/
j.japh.2019.02.005. e1.
[15] Begun J.W., Zimme man B., Dooley K. Heal h ca e o ganiza ions as complex
adap i e sys ems n.d. Ad . Heal h Ca e Manag., 2003; 253–88.
[16] Vogel M, Malco e S, Illes R, Ki kpa ick H. In eg a ed p ima y ca e: why you
should ca e and how o ge s a ed. J Men Heal h Couns 2014;36:130–44.
[17] Gillies RR, Sho ell SM, Ande son DA, Mi chell JB, Mo gan KL. Concep ualizing
and measu ing in eg a ion: indings om he heal h sys ems in eg a ion s udy.
Hosp Heal h Se Adm 1993;38:467–90.
[18] Ahg en B, Axelsson R. E alua ing in eg a ed heal h ca e: a model o measu emen .
In J In eg Ca e 2005;5:1–9. h ps://doi.o g/10.5334/ijic.134.
[19] Sun X, Tang W, Ye T, Zhang Y, Wen B, Zhang L. In eg a ed ca e: a comp ehensi e
bibliome ic analysis and li e a u e e iew. In J In eg Ca e 2014;14:e017.
[20] Goodwin N. Unde s anding in eg a ed ca e. In J In eg Ca e 2016;16:6. h ps://
doi.o g/10.5334/ijic.2530.
[21] Ma in L, Knowles EE. Model o an in eg a ed heal h sys em. J In eg Ca e 2020;
28:161–70. h ps://doi.o g/10.1108/JICA-08-2019-0034.
[22] Shigaye a A, A un R, McKee M, Coke R. Heal h sys ems, communicable diseases
and in eg a ion. Heal h Policy Plan 2010;25:i4–20. h ps://doi.o g/10.1093/
heapol/czq060.
[23] Lea P, Pink GH, Gue ie e M. Towa ds a Canadian model o in eg a ed heal hca e.
Heal hc Pap 2000;1:13–35.
[24] Sho ell SM, Gillies RR, Ande son DA, Mi chell JB, Mo gan KL. C ea ing o ganized
deli e y sys ems: he ba ie s and acili a o s. Hosp Heal h Se Adm 1993;38:
447–66.
[25] Pollock D, Da ies EL, Pe e s MDJ, T icco AC, Alexande L, McIne ney P, e al.
Unde aking a scoping e iew: a p ac ical guide o nu sing and midwi e y
s uden s, clinicians, esea che s, and academics. J Ad Nu s 2021;77:2102–13.
h ps://doi.o g/10.1111/jan.14743.
[26] T icco AC, Lillie E, Za in W, O’B ien KK, Colquhoun H, Le ac D, e al. PRISMA
ex ension o scoping e iews (PRISMA-ScR): checklis and explana ion. Ann In e n
Med 2018;169:467–73. h ps://doi.o g/10.7326/M18-0850.
[27] Le ac D, Colquhoun H, O’B ien KK. Scoping s udies: ad ancing he me hodology.
Implemen Sci 2010;5:69. h ps://doi.o g/10.1186/1748-5908-5-69.
[28] Nilsen P. Making sense o implemen a ion heo ies, models and amewo ks.
Implemen Sci 2015;10:53. h ps://doi.o g/10.1186/s13012-015-0242-0.
[29] A ksey H, O’Malley L. Scoping s udies: owa ds a me hodological amewo k. In J
Soc Res Me hodol 2005;8:19–32. h ps://doi.o g/10.1080/
1364557032000119616.
[30] Ha ne PJ. Imp o emen a ibu es in heal hca e: implica ions o in eg a ed ca e.
In J Heal h Ca e Qual Assu 2018;31:214–27. h ps://doi.o g/10.1108/IJHCQA-
07-2016-0097.
[31] Bu ows KE, Abelson J, Mille PA, Le ine M, Vans one M. Unde s anding heal h
p o essional ole in eg a ion in complex adap i e sys ems: a mul iple-case s udy o
C. Pique -Ma inez e al.
Heal h policy 141 (2024) 104997
9
physician assis an s in On a io, Canada. BMC Heal h Se Res 2020;20:365.
h ps://doi.o g/10.1186/s12913-020-05087-8.
[32] Edg en L. The meaning o in eg a ed ca e: a sys ems app oach. In J In eg Ca e
2008;8. h ps://doi.o g/10.5334/ijic.256.
[33] Edg en L, Ba na d K. Complex adap i e sys ems o managemen o in eg a ed
ca e. Leade sh Heal h Se 2012;25:39–51. h ps://doi.o g/10.1108/
17511871211198061.
[34] McDaniel RR, D iebe DJ, Lanham HJ. Heal h ca e o ganiza ions as complex
sys ems: new pe spec i es on design and managemen . In: Goes J., Sa age G.T.,
F iedman L., edi o s. Ad ances in heal h ca e managemen , 15. Eme ald G oup
Publishing Limi ed; 2013. p. 3–26.
[35] Jo don M, Lanham HJ, Ande son RA, McDaniel RR, McDaniel J RR. Implica ions
o complex adap i e sys ems heo y o in e p e ing esea ch abou heal h ca e
o ganiza ions. J E al Clin P ac 2010;16:228–31. h ps://doi.o g/10.1111/j.1365-
2753.2009.01359.x.
[36] Tsasis P, E ans JM, Owen S. Re aming he challenges o in eg a ed ca e: a
complex-adap i e sys ems pe spec i e. In J In eg Ca e 2012;12. h ps://doi.o g/
10.5334/ijic.843.
[37] McVica KL, I ani skaya LV, B adley DW, Mon e o JT. P ima y ca e and public
heal h collabo a ion epo s: a quali a i e e iew o in eg a ion aims, pa icipan s,
and success de e minan s. Popul Heal h Manag 2019;22:422–32. h ps://doi.o g/
10.1089/pop.2018.0160.
[38] Tschudy MM, Toomey SL, Cheng TL. Me ging sys ems: in eg a ing home isi a ion
and he amily-cen e ed medical home. Pedia ics 2013;132:S74–81. h ps://doi.
o g/10.1542/peds.2013-1021E.
[39] Blanken M, Ma hijssen J, an Nieuwenhuizen C, Raab J, an Oe s H. C oss-sec o al
collabo a ion: compa ing complex child se ice deli e y sys ems. J Heal h O gan
Manag 2022;36:79–94. h ps://doi.o g/10.1108/JHOM-07-2021-0281.
[40] De Jong I, Jackson C. An e alua ion app oach o a new pa adigm–heal h ca e
in eg a ion. J E al Clin P ac 2001;7:71–9. h ps://doi.o g/10.1046/j.1365-
2753.2001.00285.x.
[41] Lachance LL, F iedman Milano ich AR, Ga i y AN. Clinic and communi y: he
oad o in eg a ion. Am J P e Med 2016;51:1072–8. h ps://doi.o g/10.1016/j.
amep e.2016.09.006.
[42] Swa z CH, Ben ley S. De eloping go e nance s uc u es in heal h ca e sys em
consolida ion: a amewo k o nu se leade s. Nu s Adm Q 2016;40:292–8. h ps://
doi.o g/10.1097/NAQ.0000000000000181.
[43] Wa e man RH, Pe e s TJ, Phillips JR. S uc u e is no o ganiza ion. Bus Ho iz 1980;
23:14–26. h ps://doi.o g/10.1016/0007-6813(80)90027-0.
[44] Singe SJ, Ke issey M, F iedbe g M, Phillips R. A comp ehensi e heo y o
in eg a ion. Med Ca e Res Re 2020;77:196–207. h ps://doi.o g/10.1177/
1077558718767000.
[45] Kaasa S, Loge JH, Aap o M, Alb eh T, Ande son R, B ue a E, e al. In eg a ion o
oncology and pallia i e ca e: a Lance Oncology Commission. Lance Oncol 2018;
19:e588–653. h ps://doi.o g/10.1016/S1470-2045(18)30415-7.
[46] Tsasis P, E ans JM, Fo es D, Jones RK. Ou come mapping o heal h sys em
in eg a ion. J Mul idiscip Heal hc 2013:99. h ps://doi.o g/10.2147/JMDH.
S41575.
[47] Sho ell SM, Gillies RR, Ande son DA. The new wo ld o managed ca e: c ea ing
o ganized deli e y sys ems. Heal h A 1994;13:46–64. h ps://doi.o g/10.1377/
hl ha .13.5.46.
[48] Benham-Hu chins M, Clancy TR. Social ne wo ks as embedded complex adap i e
sys ems. JONA J Nu s Adm 2010;40:352–6. h ps://doi.o g/10.1097/
NNA.0b013e3181ee42bc.
[49] T ybou J, Gemmel P, Annemans L. The ies ha bind: an in eg a i e amewo k o
physician-hospi al alignmen . BMC Heal h Se Res 2011;11:36. h ps://doi.o g/
10.1186/1472-6963-11-36.
[50] Calciola i S, Ilinca S. Compa ing (and lea ning om) in eg a ed ca e ini ia i es: an
analy ical amewo k. J In eg Ca e 2011;19:4–13. h ps://doi.o g/10.1108/
14769011111191412.
[51] Reed S, E ans EJ, Hooyman N. Social wo k: leading he mo e ups eam o imp o e
he Na ion’s Heal h. Heal h Soc Wo k 2021;45:77–9. h ps://doi.o g/10.1093/
HSW/HLAA006.
[52] Sa ka NDPP, Baingana F, C iel B. In eg a ion o pe ina al men al heal h ca e in o
dis ic heal h se ices in Uganda: why is i no happening? The Fou Domain
In eg a ed Heal h (4DIH) explana o y amewo k. Soc Sci Med 2022;296:113464.
h ps://doi.o g/10.1016/j.socscimed.2020.113464.
[53] Be glund H, Blombe g S, Dun´
e A, Kjellg en K. O ganizing in eg a ed ca e o olde
pe sons: s a egies in Sweden du ing he pas decade. J Heal h O gan Manag 2015;
29:128–51. h ps://doi.o g/10.1108/JHOM-04-2013-0082.
[54] Axelsson R, Axelsson SB. In eg a ion and collabo a ion in public heal h–a
concep ual amewo k. In J Heal h Plan Manag 2006;21:75–88. h ps://doi.o g/
10.1002/hpm.826.
[55] Reynolds HW, Su he land EG. A sys ema ic app oach o he planning,
implemen a ion, moni o ing, and e alua ion o in eg a ed heal h se ices. BMC
Heal h Se Res 2013;13:168. h ps://doi.o g/10.1186/1472-6963-13-168.
[56] VanDeusen Lukas C, Me e ko M, Lowcock S, Donaldson-Pa lie R, Blakely M,
Da ies M, e al. Moni o ing he p og ess o sys em in eg a ion. Qual Manag Heal h
Ca e 2002;10:1–11. h ps://doi.o g/10.1097/00019514-200210020-00004.
[57] U ionagüena A, Pique -Ma inez C, Gas elu u ia M´
A, Ben imoj SI, Ga cia-
Ca denas V, Fe nandez-Llimos F, e al. Communi y pha macy and p ima y heal h
ca e– ypes o in eg a ion and hei applicabili y: a na a i e e iew. Res Soc Adm
Pha m 2023;19:414–31. h ps://doi.o g/10.1016/j.sapha m.2022.10.007.
[58] Sims S, Fle che S, B ea ley S, Ross F, Man ho pe J, Ha is R. Wha does success
look like o leade s o in eg a ed heal h and social ca e sys ems? A ealis e iew.
In J In eg Ca e 2021;21:26. h ps://doi.o g/10.5334/ijic.5936.
[59] Nguyen AM, Wood SJ, Johnson CE, Dowling WL. A concep ual model o
physician-sys em in eg a ion: a scoping e iew. J Hosp Adm 2019;8:34. h ps://
doi.o g/10.5430/jha. 8n5p34.
[60] Singe SJ, Bu ge s J, F iedbe g M, Rosen hal MB, Leape L, Schneide E. De ining
and measu ing in eg a ed pa ien ca e: p omo ing he nex on ie in heal h ca e
deli e y. Med Ca e Res Re 2011;68:112–27. h ps://doi.o g/10.1177/
1077558710371485.
[61] Ryan K, Pa el N, Lau WM, Abu-Elmagd H, S e ch G, Pinney H. Pha macis s in
gene al p ac ice: a quali a i e in e iew case s udy o s akeholde s’ expe iences in
a Wes London GP ede a ion. BMC Heal h Se Res 2018;18:234. h ps://doi.o g/
10.1186/s12913-018-3056-3.
[62] A mi age GD, Sys ems H, Heal h A, Calga y S, Su e E, Oelke ND, e al. Heal h
sys ems in eg a ion: s a e o he e idence. In J In eg Ca e 2009;9. h ps://doi.
o g/10.5334/ijic.316.
C. Pique -Ma inez e al.
