Strategies for integrating primary health services in middle- and low-income countries at the point of delivery
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.
Briggs, C.J.; Garner, P. Strategies for integrating primary health services in middle- and low-income countries at the point of delivery. Cochrane Database of Systematic Reviews (2006) (Issue 2) Art. No.: CD003318. [DOI: 10.1002/14651858.CD003318.pub2]