Integrating healthcare services in low- and middle-income countries

In some low- and middle-income countries, healthcare services are organised around a specific health problem. This can cause fragmentation as people are required to visit separate clinics depending on their health problem or need. The logic is that specialist clinics lead to better care and health outcomes because skilled healthcare providers then provide the specialised services and technologies related to the healthcare need. On the other hand, separating out services for specific diseases can be inefficient for both the provider, with service duplication, and the patient who has to visit different services for their health care. For example, a mother has to go to one clinic for family planning services and another for her children to be vaccinated, or a person with HIV and TB has to go to separate clinics for each disease.

One solution is to integrate healthcare services at the point of delivery or to strengthen the linkages between the services. The purpose of integration is to improve co-ordination and service delivery by providing services together, for example services for mothers and their children in one centre. It is believed that integration ensures that services are managed and delivered together, for an efficient and high quality service. It is also believed that integration of care leads to greater public access, including more equitable access for people from different communities and socio-economic backgrounds, a more convenient and satisfying service, and better health overall. Others believe that, with integration of care, healthcare professionals might become overloaded or not have the specialised skills to manage specific diseases, which could lead to poor quality services and poor health.

This updated review included nine studies that evaluated integrated care or linkages in care. The studies made two types of comparison.

1) Integration of care, by adding a service to an existing service (tuberculosis (TB) or sexually transmitted infection (STI) patients were offered HIV testing and counselling; mothers attending an immunisation clinic were encouraged to have family planning services).

2) Integrated services versus single, special services (family planning, maternal and child health delivered as a special vertical programme or integrated into routine healthcare delivery).

There was some evidence from the included studies that adding on services or creating linkages to an existing service improved its use and delivery of health care but little or no evidence that fuller integration of primary healthcare services improved people's health status in low- or middle-income countries. People should be aware that integration may not improve service delivery or health status.If policy makers and planners consider integrating healthcare services they should monitor and evaluate them using good study designs.

Authors' conclusions: 

There is some evidence that 'adding on' services (or linkages) may improve the utilisation and outputs of healthcare delivery. However, there is no evidence to date that a fuller form of integration improves healthcare delivery or health status. Available evidence suggests that full integration probably decreases the knowledge and utilisation of specific services and may not result in any improvements in health status. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. These studies should include economic evaluation and the views of clients as clients' views will influence the uptake of integration strategies at the point of delivery and the effectiveness on community health of these strategies.

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Background: 

In some low- and middle-income countries, separate vertical programmes deliver specific life-saving interventions but can fragment services. Strategies to integrate services aim to bring together inputs, organisation, and delivery of particular functions to increase efficiency and people's access. We examined the evidence on the effectiveness of integration strategies at the point of delivery (sometimes termed 'linkages'), including integrated delivery of tuberculosis (TB), HIV/AIDS and reproductive health programmes.

Objectives: 

To assess the effects of strategies to integrate primary health care services on healthcare delivery and health status in low- and middle-income countries.

Search strategy: 

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 3, part of the The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care Group Specialised Register (searched 15 September  2010); MEDLINE, Ovid (1950 to August Week 5 2010) (searched 10 September  2010); EMBASE, Ovid (1980 to 2010 Week 35) (searched 10 September  2010); CINAHL, EBSCO (1980 to present) (searched 20 September 2010); Sociological Abstracts, CSA Illumina (1952 to current) (searched 10 September  2010); Social Services Abstracts, CSA Illumina (1979 to current) (searched 10 September  2010); POPLINE (1970 to current) (searched 10 September  2010); International Bibliography of the Social Sciences, Webspirs (1951 to current) (searched 01 July 2008); HealthStar (1975 to September 2005), Cab Health (1972 to 1999), and reference lists of articles. We also searched the World Health Organization (WHOLIS) library database, handsearched relevant WHO publications, and contacted experts in the field.

Selection criteria: 

Randomised controlled trials, non-randomised controlled trials, controlled before and after studies, and interrupted time series analyses of integration strategies, including strengthening linkages, in primary health care services. Health services in high-income countries, private public partnerships, and hospital inpatient care were excluded as were programmes promoting the integrated management of childhood illnesses. The main outcomes were indicators of healthcare delivery, user views, and health status.

Data collection and analysis: 

Two authors independently extracted data and assessed the risk of bias. The statistical results of individual studies are reported and summarised.

Main results: 

Five randomised trials and four controlled before and after studies were included. The interventions were complex.

Five studies added an additional component, or linked a new component, to an existing service, for example, adding family planning or HIV counselling and testing to routine services. The evidence from these studies indicated that adding on services probably increases service utilisation but probably does not improve health status outcomes, such as incident pregnancies.

Four studies compared integrated services to single, special services. Based on the included studies, fully integrating sexually transmitted infection (STI) and family planning, and maternal and child health services into routine care as opposed to delivering them as special 'vertical' services may decrease utilisation, client knowledge of and satisfaction with the services and may not result in any difference in health outcomes, such as child survival. Integrating HIV prevention and control at facility and community level improved the effectiveness of certain services (STI treatment in males) but resulted in no difference in health seeking behaviour, STI incidence, or HIV incidence in the population.