IFIC 9 Pillars of Integrated Care
Revision and validation 2024-2025
Lead and corresponding author
Niamh Lennox-Chhugani, Chief Executive and Director of Research, International Foundation for Integrated Care, nlennoxchhugani@integratedcarefoundation.org
Suggested citation.
IFIC’s Nine Pillars of Integrated Care: Revision and Validation 2024-2025: International Foundation for Integrated Care. 2026.
Introducing the Nine Pillars of Integrated Care
The International Foundation for Integrated Care (IFIC) has been the global leader in generating, curating and sharing knowledge and evidence on integrated care policy and practice since 2011.
IFIC is a trusted source of information and knowledge in relation to integrated care. We use this knowledge to promote our mission to inspire, influence and facilitate the adoption of inclusive community-centred integrated care in policy and practice around the world.
We know that policy-makers, system leaders and health and care professionals come to us when they need accessible knowledge that can be applied in practice. We also know that leading academics and researchers in the field of integrated care use our resources, such as the International Journal of Integrated Care, the International Conference on Integrated Care and our networks to share and disseminate their research. IFIC’s goal is to bring these two constituencies and act to mobilise knowledge to action. The Nine Pillars of Integrated Care is the framework within which we do that.
In 2020, IFIC published the Nine Pillars of Integrated Care in a paper that set out IFIC’s Call to Action to speed up the shift to integrated care across the world (1). This paper, authored by IFIC’s research team with contributions from integrated care experts across the global network, identified the Nine Pillars as the conditions of any health and care system that need to be in place for integrated care to sustain and scale. The original Nine Pillars can be found in Appendix 1.
At IFIC we use the Nine Pillars as a meta-framework, that is, a higher-level framework that combines and includes other frameworks. A framework is generally understood as a broad structure that identifies and organises key concepts, variables, or domains relevant to a phenomenon, without necessarily specifying the causal or mechanistic relationships between them (2). As a meta-framework, the Nine Pillars is a higher-order construct that synthesises, integrates, or organises multiple existing frameworks into a unified structure (3). Thus, the intent is to complement the many approaches to integrated care design and evaluation that have proliferated over the past decade.
This meta-framework has served as a strategic framework for us at IFIC, guiding the organisation of conferences and events, structuring our knowledge and informing empirical research during independent evaluations. This use has highlighted the contribution the Pillars make to the policy and practice of integrated care in different contexts. Our goal is that this meta-framework will enable IFIC to categorise and compare these frameworks and help researchers and practitioners identify the most suitable tools for designing, implementing, and evaluating integrated care initiatives across diverse contexts.
The Nine Pillars published in 2020 had not been formally tested or validated as part of the first publication. The framework has been widely used as a reference by policy makers and practitioners within IFIC’s network. To build on this, it is essential to strengthen its conceptual development and validate the Nine Pillars ensuring the meta-framework is consistent with what we know from research and practice in integrated care.
To address this validation gap, a methodology to revise and validate the Nine Pillars of Integrated Care was designed and conducted. This document summarises the revision and validation work which was undertaken over 14 months. It also presents the revised Nine Pillars of Integrated Care, the descriptions of each Pillar and the next steps for the development of the Nine Pillars.
Concepts, definitions and frameworks for integrated care
Over the past 15 years, a wide variety of approaches have been developed to support the design, implementation, and evaluation of integrated care (4). Rather than replace these, the Nine Pillars of Integrated Care as a meta-framework, serves as a structured lens though which such approaches and strategies can be compared, assessed, and strengthened.
A recent review of peer-reviewed, and grey literature conducted by IFIC’s research team with consortium partners as part of LAUREL[1] project identified 69 integrated care frameworks, using defined inclusion and exclusion criteria
Integrated care works best when services are coordinated across settings (5) (Appendix 2). The frameworks identified were developed and applied by researchers, policymakers and implementers of integrated care initiatives. Each was assessed for integrated care comprehensiveness, generalisability and real-world application, resulting in a shortlist of 26. These selected approaches were then systematically analysed against the Nine Pillars, enabling IFIC to answer the following questions in this review:
- Which Pillars are well represented in integrated care frameworks?
- Which Pillars remain underdeveloped in frameworks?
- Where would the Nine Pillars themselves benefit from greater specificity or refinement?
[1] LAUREL is a project funded by the EU Commission to develop actionable policy insights on integrated long-term care. Grant Agreement Number 10132643. More information can be found at https://laurelproject.eu/
The Nine Pillars of Integrated Care 2020
The original Nine Pillars of Integrated Care (2020) are presented in Figure 1 below. The detailed descriptions under each Pillars were described in some detail in the original publication. Short summaries of these descriptions are listed in Appendix 1. The original work was developed and published at the beginning of the Covid-19 pandemic and as such the context of the pandemic and the health system challenges being faced at the time dominate the narrative. The revision of the Nine Pillars takes the meta-framework out of this specific context to provide greater generalisation.
Review method
The literature review used the rapid literature review method6 to collate and summarise the literature on integrated care frameworks across health and relevant social science disciplines. Our aim was to identify integrated care frameworks that have been theorised and applied in policy and practice in a range of different settings and for different population groups, consider how they been variably conceptualised, theorised and used empirically by researchers and practitioners and highlight the range of scope of the frameworks in terms of the system levels (micro, meso and macro). The figure below summarises the review process undertaken7 using PRISMA 2020. The abstract screening process was supported using the Rayyan application and used inclusion / exclusion criteria as summarised in Appendix 2.
Review findings
The full text reviews of the 69 studies identified through abstract screening were then reviewed by IFIC’s research team with further exclusion criteria applied through a process of full text screening (Appendix 2). 26 studies were included in the final stage of review. The purpose of this final review was to use the 26 frameworks to assess the comprehensiveness of the Nine Pillars of Integrated Care and identify any gaps in the meta-framework.
The 26 frameworks identified by the full text screening (Appendix 3) were analysed by mapping in two stages. The first stage involved mapping the scope of the frameworks against the system levels they covered – macro, meso, micro. To support this analysis, the team first defined the system levels.
Table 1. Definitions of systems levels
| Level | Definition |
|---|---|
| Macro | The supra-system level and the milieu that directly or indirectly affects the existence and functioning of the public health system. It incorporates phenomena such as the social, political, and economic forces operating in the overall society (8). |
| Meso | Regional, district/county, or institutional / organisational level (9) (10) |
| Micro | Clinical teams, programmes and community interventions (any level below institutional) (10) (11) |
Analysis was based on information published in the source document (published study in peer-reviewed journal or briefing paper to accompany the framework in the case of grey literature). It is possible that these frameworks have been used at levels other than those mapped here, but this was not identified in the full text screen. The second step mapped each framework’s content against the Nine Pillars of Integrated Care.
Step 1: Mapping the frameworks against the levels of analysis
As a meta-framework, IFIC’s Nine Pillars of Integrated Care needs to be used at all three system levels. Not all the 26 integrated care frameworks reviewed will have been intended for use at all three levels. Some may have been very purposefully designed to be used at one level only. A table summarising the system level mapping is included in Appendix 4.
Frameworks that can be applied at all three levels of the system
14 of the 26 frameworks were found to be applicable at micro, meso and macro levels. A further six frameworks could be applied at all three levels but at least one level was only partially addressed.
Frameworks that can be applied at only one level of the system
Three frameworks can only be applied at one level of the system. Two of these are applied at micro level, the interface between the person at the centre of care and health and care providers and one is applied at macro level only.
Frameworks that can be applied at two levels of the system
The remaining three frameworks can be applied at two levels of the system. Two of these focused on the micro and meso levels and one on the meso and macro levels.
Step 2: Mapping the content of the frameworks to the Nine Pillars
The team used the Nine Pillars (2020) to map the content of the 26 frameworks against the Pillars. This allowed us to compare the frameworks against the Nine Pillars and answer the questions for the review:
- Which Pillars are well represented in integrated care frameworks?
- Which Pillars remain underdeveloped in frameworks?
- Where would the Nine Pillars themselves benefit from greater specificity or refinement?
Which Pillars are well represented in integrated care frameworks?
The Pillar consistently included in some form in all 26 frameworks was “people as partners in care”. “Workforce capacity and capability” was included by 20 out of 26. There was inclusion of some form of “transparency of impact” in 17 frameworks, usually reference to a specific set of measures to be used when monitoring integrated care.
Which Pillars remain underdeveloped in frameworks?
“Aligned payment systems” was the Pillar least referenced by other frameworks. It was included in 13 out of 26 frameworks. The other Pillars were covered by 15-16 frameworks each.
Within the “workforce capacity and capability” Pillar, the reviewed frameworks commonly referenced “interprofessional”, “interdisciplinary” or “multidisciplinary” teamwork as primary mechanisms of integrated care. The original Pillar description referred to “blurring of roles” in integrated care but did not explicitly reference the kind of teamwork referred to in the reviewed frameworks.
It was also clear from the framework review that many of the frameworks had been through a lengthy and rigorous process of design, testing and validation in context. Some of the frameworks were the products of multi-year, multi-country, inter-disciplinary research.
Where would the Nine Pillars themselves benefit from greater specificity or refinement?
Eight of the 26 frameworks included content related to service design in some cases specific to a population group (for example, older people). This had not previously been included in the Nine Pillars. This raised the question for the IFIC research team: Should the Nine Pillars include a Pillar related to service design? This question was taken forward into the next stage of the Nine Pillar revision.
Revising the Nine Pillars of Integrated Care
The Nine Pillar Labels
The mapping exercise highlighted further the pandemic-specific nature of the descriptions on the Nine Pillars. The labels and the descriptions lacked specificity (capable of being sufficiently context specific to a health and care system at any level) and their generalisability (wide application across many systems) had not been validated. To start this process of validation, the IFIC research team developed changes to the labels and short description of the Nine Pillars to reflect the scope of research and practice in integrated care across the world, enhancing the specificness and generalisability of the Nine Pillars as a meta-framework.
The IFIC research team worked collaboratively to refine the current set of short titles used for the Nine Pillars based on the framework review. Consensus was reached on a revised set of titles used for the Nine Pillars[2] and they are summarised below. The intent of the title is to provide a shorthand that can be used for graphics. Each title needed to balance breadth and inclusiveness with specificity. The short descriptions are intended to be used alongside the titles and provide additional information.
[2] Five senior researchers with expertise in integrated care research independently reviewed the original labels and descriptions and assessed proposed new levels and descriptions. A consensus meeting was convened to arrive at consensus for those labels where there was most dissensus.
Table 2. Nine Pillar labels - 2020 and revision in 2025
| 2020 Pillar Title | 2025 Pillar Title | |
|---|---|---|
| Shared values and vision | Purpose | Shared purpose |
| Population health and local context | Health in context | Understanding of the determinants of health in context |
| People as partners in care | People as partners | People and communities as partners in care |
| Resilient communities and new alliances | ||
| Workforce capacity and capability | Teamwork | Integrated teamwork that is person and community-centred |
| Sub-domain of Workforce: Professional practice | ||
| Sub-domain of Workforce: Care coordination | Coordinated care | Service delivery models that promote care coordination |
| System wide governance and leadership | Governance | Shared accountability, governance and leadership |
| Digital solutions | Information and technology | Shared information and digital technology |
| Aligned payment systems | Finance | Aligned payment and funding systems |
| Transparency of progress, results and impact | Learning | Learning from results and impact |
The short descriptions outlined above were the titles used for the meta-framework validation using the modified Delphi method. The only exception to this was the short description used for Information and technology. The first round of the Delphi used the description Digital technology and information enabled integrated care but feedback from the Delphi panel was that this did not reflect the priority order of the related concepts of information and technology, so this was adapted to Shared information and digital technology.
The Nine Pillar descriptions
Using the analysis of frameworks and our experience of using the Nine Pillars, the IFIC research team drafted revised explanatory descriptions of the Nine Pillars. These descriptions were presented to the group of experts using a modified Delphi method.
The modified Delphi method
A panel of 50 international experts in integrated care from 20 countries were invited to take part in the Delphi process. Experts were drawn from The Scientific Committee of IFIC’s annual International Conference on Integrated Care and included academics, policymakers and practitioners of integrated care who have been participants in the network for at least a decade. Of these 36 invitees expressed an interest in being involved in the Delphi panel.
The aim of the panel was to work towards consensus on the descriptions of IFIC’s Nine Pillars of Integrated Care. There were three rounds of the Delphi Panel over 6 months from September 2024 to February 2025.
ROUND 1
In the preliminary round (ROUND 1), the 36 panellists were sent background materials to read including the review of the integrated care frameworks. The survey presented the panellists with the proposed descriptions for each of the Nine Pillars. They were asked to highlight any missing information from the descriptions and any wording they did not agree with. They were asked to provide alternative wording for inclusion in revised descriptions. 29 panellists responded to this round.
Two members of IFIC research team independently analysed anonymised responses to the ROUND 1 survey contemporaneously, then met and compared their analysis resolving through discussion any differences in analysis. Three researchers then synthesized the proposed changes to the descriptions. Feedback from this round prompted the researchers to develop a general description for each Pillar and additionally a description from the points of view of three groups, (1) people and communities, (2) care providers, and (3) system-level decision-makers.
ROUND 2
The revised descriptions were presented to the 29 panellists in ROUND 2. The experts were asked to score the content and wording of each description on a seven-point scale (strongly agree – strongly disagree). If they scored “disagree”, they were asked to provide the wording they would prefer in an amended version. 25 experts completed ROUND 2.
A member of the IFIC research team analysed the level of consensus from the scoring of the 25 responses. The consensus threshold was set at ≥75% (12). The wording suggestions were reviewed, and the descriptions were further modified for ROUND 3. These modifications were changes in emphasis and providing greater clarity rather than the more substantive modifications after ROUND 1.
ROUND 3
In the final round, ROUND 3, each of the 25 experts was sent a survey with the consensus score from ROUND 2 and their response to ROUND 2. They were invited at that point to amend their score using a five-point scale (strongly agree – strongly disagree) or if they wished to retain their previous score, explain why it should remain as it is. The data collected from the 22 panellists how responded was analysed for consensus by a member of the IFIC research team and subsequently checked by one other. In this round, the consensus levels did not drop below 86% for any Pillar. A summary of the levels of consensus for each Pillar in ROUND 2 and 3 are found in Appendix 5.
The participation rates at each stage of the Delphi process are summarised in the table below.
Table 3. Delphi panel participation rates
| Milestone | Number of experts | ||
|---|---|---|---|
| Invited to take part | 50 | n/a | n/a |
| Expressed an interest in taking part | 36 | 72% | 72% |
| Round 1 response | 29 | 58% | 81% |
| Round 2 response | 25 | 50% | 86% |
| Round 3 response | 22 | 44% | 88% |
The results of the modified Delphi panel – consensus and disagreement
The final descriptions for each Pillar that emerged from the Delphi panel process are presented in Appendix 6. For four of the nine Pillars, while a good level of consensus was reached, there remained some dissent and debate.
A notable comment from one panellist repeated for multiple Pillar’s related to the how the descriptions were framed. The descriptions were deliberately framed as “what good looks like”, that is, the ideal description if the Pillar were to be present in a mature integrated care system. This panellist pointed out that such a framing may be counter-productive, being so far from reality that it would be difficult to see how it could be delivered and progress to delivery measured. We acknowledge this challenge and one of the tools we are developing is a maturity self-assessment tool that can be adapted to the local context and enable those conversations about delivery and progress to be had.
Another common reflection which resonated for the IFIC research team, was how to represent the inter-dependencies between the Pillars in the descriptions. This will be addressed in the as part of our ongoing development of the Pillars as IFIC shares working examples of those inter-dependencies from practice through case studies and practice sharing.
An outstanding dissent which emerged over multiple Pillars which should also be addressed in the ongoing iteration of the Nine Pillars, was the focus on universal coverage. This, and the tendency of Pillar descriptions to be ideologically aligned to a social justice perspective on health and care and assume predominantly single funder (state) models, led to some criticism from panellists that the Nine Pillars were not inclusive of other perspectives, such as the business case for integrated care in social insurance and privately financed health and care system, and jurisdictions where universal coverage is not the reality.
Shared purpose for integrated care
There was strong consensus on the importance of this Pillar in all rounds of the Delphi process. There was also consensus on the proposed wording with suggestions to expand the scope to be more explicitly inclusive of the policy-making realm.
Determinants of population health in context
This was one of the Pillars in which there was more dissent. This dissent related mainly to the use of language, definition of concepts and the relationship between the wider determinants of population health and integrated care. ROUND 2 and 3 both focused on clarifying and refining the language used and the relationship between integrated care and population health. The detailed descriptions from the point of view of different groups provided an opportunity to stipulate this additional clarity. Nonetheless, there remained dissent on the relationship between integrated care and population health with two panellists holding the view that population health is an outcome of integrated care and much else besides. We acknowledge that this remains an ongoing and constructive debate in the movement.
People and communities as partners in care
As with “Purpose”, there was strong consensus on the importance of this Pillar in all rounds of the Delphi process. There was also consensus on the proposed wording with suggestions to expand the scope to be more explicitly inclusive of the co-production with people and communities from all stakeholder points of view.
Integrated teamwork for person- and community-centred care
There was very strong consensus on the importance of this Pillar in all rounds. In ROUND 1, there were suggestions to include education and training as enablers of integrated teamwork as well as acknowledging the role that professional hierarchies and power relations play in such teamwork. Much of the focus in subsequent rounds was on clarifying the language used in the description.
Service delivery for coordinated and integrated care
This was a new Pillar introduced to address the gap in the Nine Pillars identified in the framework review. There was strong consensus on the description of this Pillar but ROUND 1 identified some important clarifying requirements. While there is a diversity of service delivery options for integrated care, a clear emphasis should be placed on coordination as a mechanism for integration at micro and meso levels. Another clarification related to the scope of service delivery as inclusive of not-for-profit and for-profit providers of health and care and explicit mention of social care. The description was also expanded to include a range of populations on a continuum from disease-specific through to whole populations.
Shared accountability, governance and leadership
There was strong consensus among the panellists that all three elements of accountability, governance and leadership are important scaffolding for the delivery of integrated care. Context is particularly important here. Systems have varied history, ideology and structure and the description needs to be adaptive to a wide range of situations. Some of the areas of dissent were specific to certain types of systems. This reinforces our approach of balancing specificity of the Nine Pillar descriptions with adaptability to context.
Digital technology and information enabled integrated care (Information and technology)
While there was consensus around this Pillar overall, this is one of the Pillars where that consensus was weaker with panellists more likely to “agree” with a description than “strongly agree”. There was consensus that shared information was essential for effective inter-disciplinary team working. There were suggestions to include greater specificity on how this could be realised at the micro level, but these were high income country specific. One panellist did not agree that this was an essential Pillar for inclusion seeing it as a “tool” to enable integration. For others, the focus needed to be more on “information” with “digital” as one mechanism to deliver the information needed at micro, meso and macro levels to enable integrated care.
Aligned payment and funding (Financing)
There was generally strong consensus on this Pillar, but some panellists in ROUND 1 Pillar pointed out that the description was too focused on state-funded universal coverage financing models. The final version has attempted to open up the description, but this will need to continue to be iterated in collaboration with IFIC’s network in the field of practice.
Learning from results and impact
This was another Pillar where consensus was weaker. Three panellists were unsure that the description was sufficiently detailed. Again, a balance was sought between including enough detail to be useful while acknowledging that contexts are different and the description needs to be inclusive of this difference. There were common reflections on the dependency of this Pillar with other Pillars such as Governance, Information and Finance. The feedback from panellists in ROUND 1 and 2 highlighted the importance of learning at all levels, that is, where care is delivered, across organisations and at the level of the wider system. This was incorporated into the final descriptions for ROUND 3.
Refining the language of the Nine Pillars
One feedback from the Delphi panellists in ROUND 1 was the complexity of the concepts and language that the Nine Pillars of Integrated Care is trying to synthesise. This is an acknowledged problem and has been the source of criticism of the many of the frameworks that were reviewed in the initial phase of this work. This was resolved to some extent through subsequent rounds of the Delphi panel. However, even accounting for the different perspectives, the group of Delphi panellists are all very familiar with the language and concepts of integrated care.
For IFIC, an important next step, is to refine the language of the Nine Pillars to make it easier for non-experts to understand and apply.
The IFIC research team used the opportunity, when commissioned to develop an introductory course on integrated care, to seek feedback on the understandability of the general descriptions for each Pillar to a non-expert audience of policymakers and care providers. This feedback came from multiple high income country policy makers and care providers in one European country working within the state-funded health and care system.
The output of this work is summarised in Appendix 7.
This work prompted the IFIC team to align the Pillars to the WHY WHAT and HOW of integrated care, addressing one of the queries from users about distinguishing between Pillars beyond a simple categorisation of enablers or conditions that need to be present for integrated care to happen. This is presented in Figure 3 below.
IFIC will test this version of the Nine Pillars with community groups and people with lived experience over the next 24 months.
It is likely that multiple versions of the Nine Pillars will be developed. Versions that are specific to context based on social norms, socio-political history, health and care system structures and priorities, and many other variables. To accommodate this, IFIC will host a repository where further community-based development of the Nine Pillars can be shared.
Next steps for the Nine Pillars
IFIC will test this version of the Nine Pillars with community groups and people with lived experience over the next 24 months.
It is likely that multiple versions of the Nine Pillars will be developed. Versions that are specific to context based on social norms, socio-political history, health and care system structures and priorities, and many other variables. To accommodate this, IFIC will host a repository where further community-based development of the Nine Pillars can be shared.
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Dr Niamh Lennox-Chhugani
International Foundation for Integrated Care (IFIC)