Strategies for integrating primary health services in middle- and low-income countries at the point of delivery

 

Abstract

Background

Strategies to integrate primary health care aim to bring together inputs, organisation, management and delivery of particular service functions to make them more efficient, and accessible to the service user. In some middle and low income countries, services have been fragmented by separate vertical programmes established to ensure delivery of particular technologies. We examined the effectiveness of integration strategies at the point of delivery.

Objectives

To assess the effects of strategies to integrate primary health care services on producing a more coherent product and improving health care delivery and health status.

Search strategy

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (August 2005), MEDLINE (1966 to September 2005), EMBASE (1988 to 2005), Socio Files (1974 to September 2005), Popline (1970 to September 2005), HealthStar (1975 to September 2005), Cinahl (1982 to September 2005); Cab Health (1972 to 1999), International Bibliography of the Social Sciences (1970 to 1999), and reference lists of articles. We also searched the Internet and World Health Organization (WHO) library database, hand searched relevant WHO publications and contacted experts in the field.

Selection criteria

Randomised trials, controlled before and after studies, and interrupted time series analyses of integration strategies in primary health care services. Health services in high-income countries were excluded. The primary outcomes were indicators of health care delivery, user views on any measure of service coherence, and health status. We also sought information on comparative costs.

Data collection and analysis

Two authors independently extracted data and assessed study quality.

Main results

Three cluster randomised trials and two controlled before and after studies were included, with three types of comparison: integration by adding on an additional component to an existing service (family planning); integrated services versus single special services (for sex workers); integrated delivery systems versus a vertical service (for family planning); and packages of enhanced primary child care services (integrated management of childhood illnesses) vs. routine child care. Interventions were complex and in some studies inputs varied substantially between comparison arms. Overall, no consistent pattern emerged. Only one study attempted to assess the user's view of the service provided.

Authors' conclusions

Few studies of good quality, large and with rigorous study design have been carried out to investigate strategies to promote service integration in low and middle income countries. All describe the service supply side, and none examine or measure aspects of the demand side. Future studies must also assess the client's view, as this will influence uptake of integration strategies and their effectiveness on community health.

 

Plain language summary

Integrating health care services in low- and middle-income countries

In some low- and middle-income countries, health care services have become fragmented and organised by a specific health problem. Organisation by a specific health problem or specialisation usually means people need to visit separate and specialised clinics depending on their health problem. Examples include tuberculosis clinics, HIV clinics or family planning centres. Some believe that specialisation leads to better care because health care providers are skilled in a disease and can provide specialised services and technologies related to that disease. Others believe that separating out services for specific diseases leads to inefficient services and a duplication of services. For example, a mother is assessed and provided with services at a family planning centre and then needs to visit a separate centre for vaccines for her children.

One solution to fragmented care is to provide integrated health care services. The purpose of integration is to provide services packaged together, for example services for mothers and their children in one centre. It is believed that integrating services ensures services are managed and delivered together for an efficient and high quality service. It is also believed that integration of care leads to better health overall, public access to services and equal access for people from different communities and socio-economic backgrounds, a more convenient and satisfying service. But others believe that health care professionals might become overloaded or not have specialised skills to manage specific diseases which could lead to poor quality services and poor health.

There were five studies of reasonable quality that evaluated integrated care. The studies made three types of comparison:

1) integration of care by adding a service to an existing service (mothers attending a immunisation clinic were encouraged to have family planning services);

2) integrated services versus single special services (sex workers could have services for sexually transmitted diseases in a normal clinic, in an after hours clinic or by a special team; and providing family planning services at a Maternal and Child Health Centre or separately at another clinic)

3) packages of enhanced child care services (integrated management of childhood illnesses) versus routine child care.

From the studies there was no clear evidence that integrating primary health care services improves the delivery of health services or people's health status in middle or low income countries. People should be aware that integration may not improve service delivery or health status and if policy makers and planners consider integrating health care services they should monitor and evaluate them using good study designs.