Examining Macro-Level Barriers and Facilitators to Scaling Up Integrated Care from a Complexity Perspective: A Multi-Case Study of Cambodia, Slovenia, and Belgium

Introduction: ' (SCUBY) project provides evidence on scaling-up integrated care (IC) in Cambodia, Slovenia, and Belgium. This paper examines macro-level barriers and facilitators to scaling up IC in these settings. Methods: We used a multi-case study design, with each country being a case. Document review, focus groups, and stakeholder interviews were conducted. The WHO health system building blocks guided the thematic analysis. We then visualised and examined the interlinkages between barriers in each country. Results: Common challenges to scaling up IC across the three health systems relate to: governance and leadership; health workforce; inadequate health financing system; and fragmented health information systems. In Cambodia, access to non-communicable disease (NCD) services and medicine are important issues. IC scale-up is facilitated by its strong governance and public health service model in Slovenia but health workforce shortages risk progress. In Belgium, the fragmented governance system and predominant fee-for-service provider payment are important barriers. A common response to health workforce and workload challenges was task shifting: to primary care nurses in Belgium, peer supporters in Slovenia, and community health workers in Cambodia. Conclusions: Examining differences and similarities between barriers in each health system stimulated reciprocal learning. Interactions between health system barriers in specific contexts require further attention to move complex health systems forward.