April, 2017 - SUPPORT Summary of a systematic review | print this article |

Does integration of primary healthcare services improve healthcare delivery and outcomes?

Primary healthcare in many low- and middle-income countries is organised through vertical programmes for specific health problems such as tuberculosis control or childhood immunisation. Vertical programmes can help deliver particular technologies or services, but may lead to service duplication and fragmentation. To address such problems, the World Health Organization and other organizations promote integration, where inputs, delivery, management and organization of particular service functions are brought together. Integration may involve adding a service to an existing vertical programme or full integration of services within routine healthcare delivery.

 

Key messages

  • Adding family planning to other services probably increases the utilisation of family planning; but probably results in little or no difference in the number of new pregnancies.
  • Adding provider initiated HIV counseling and testing to sexually transmitted infection services and to TB services probably increases the number of people receiving HIV testing.
  • Integrating sexually transmitted infection services for female sexual partners of truck drivers into routine primary care may reduce women’s utilisation of these services and their attendance following referral.
  • Integrated community and facility provision of HIV prevention and control improves the proportion of STIs treated effectively in males but leads to little or no difference in the proportion treated effectively in females.
  • Integrated community and facility provision of HIV prevention and control results in little or no difference in sexually transmitted disease incidence or HIV incidence in the population.
  • ‘Integration’ is a complex intervention and is understood in different ways in different settings. Evaluations need to describe clearly the interventions being compared, including how services are integrated in practice.

 

Background

Government health services in many low- and middle-income countries are frequently organised through a set of vertical programmes, each responsible for organizing a set of inputs to ensure delivery for the specific health problem being addressed (for example, HIV/AIDS or malaria prevention). Specialized, separate, vertical programmes allow central technical supervision to ‘reach out’ directly to the service delivery level. This approach is seen to have the advantage of being able to better ensure service delivery for a particular health issue. Vertical programmes, however, can also lead to service duplication, inefficiency and service fragmentation.

Integration of primary healthcare was defined in this review as “a variety of managerial or operational changes to health systems to bring together inputs, delivery, management and organization of particular service functions.” The review focused on integration at the point of delivery.



About the systematic review underlying this summary

Review objectives: To determine whether strategies that aim to integrate primary health services or strengthen linkages at the point of delivery in low- and middle-income countries produce a more coherent product and improve healthcare delivery and/or health outcomes.
Type of What the review authors searched for What the review authors found
Study designs & interventions Any management or organisational change strategy applied to existing systems that aimed to increase integration at the service delivery level in primary health. The review included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies.

5 randomised trials and 4 controlled before-after studies.

- Adding a family planning clinic to: an expanded program of immunisation (1 study), a maternal and child health service (2 studies), and a voluntary HIV counselling and testing service (1 study).

- Different forms of integration of nutrition and infectious disease control (1 study)

- Integrating sexually transmitted infection, HIV/AIDS and TB health services with routine services (4 studies).


Participants Users and providers in primary healthcare facilities in low- and middle-income countries
Individual patients, couples, households, and communities using primary healthcare services; and providers of primary healthcare services.
Settings Primary healthcare facilities in low- and middle-income countries
India (2 studies), South Africa (2 studies), Nepal, Tanzania, Togo, Zambia, Zimbabwe.
Outcomes Healthcare delivery, healthcare received, and health behaviour and status outcomes.

Processes and outputs of healthcare delivery (9 studies)

Health status (5 studies)

Knowledge and behaviours of service users (3 studies)

Users' perceptions of the service (1 study)


Date of most recent search: September 2010
Limitations: This is a well-conducted systematic review with only minor limitations.

Dudley L, Garner P. Strategies for integrating primary health services in low- and middle-income countries at the point of delivery. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD003318. 

Summary of findings

Nine studies were included in the review. They were conducted in primary healthcare services in South Africa (2 studies), India (2 studies), Zimbabwe, Tanzania, Togo, Nepal and Zambia. The identified interventions fell into two categories: adding a service to an existing vertical programme; and comparisons of vertical service delivery with a fuller integration of services.

1) Adding family planning services to other services vs usual care 

A cluster randomised trial in Togo, a randomised trial in Zambia and a controlled before -after study in India evaluated this comparison in facilities providing primary health services.

 

  • Adding family planning to other services probably increases the utilisation of family planning; but probably results in little or no difference in the number of new pregnancies. The certainty of this evidence is moderate.

 

Adding family planning services to other services compared to usual services

People            People attending facilities providing primary health services

Settings          Primary health services in Togo, Zambia and India

Intervention   Adding family planning to other services

Comparison    Usual services (without the addition of family planning)

Outcomes

Absolute effect* (95% CI)

Relative effect

(95% CI)

Number of
sites / participants

Certainty

of the

evidence

(GRADE)

Without the addition of family planning services

With the addition of family planning services

 

Change in number of mothers accepting family planning services 

23 more per month

107 more per month

 

365% increase

16 clinics

Low

Couples initiating non barrier contraception

329 per 1000

787 per 1000

(573 to 1000)

RR 2.39

(1.74 to 3.29)

251 couples

Moderate

Incident pregnancies

occurring during a one year follow-up period

220 per 1000

195 per 1000

(116 to 325)

RR 0.89

(0.53 to 1.48)

251 couples

Moderate

*The assumed risk WITHOUT the intervention is based on the control group of each study. The corresponding risk WITH the intervention is based on the overall relative effect.

CI: Confidence interval. RR: Relative risk. GRADE: GRADE Working Group grades of evidence (see above and last page)


2) Adding Provider Initiated HIV Testing and Counseling at primary health facilities vs routine services

One cluster randomised trial and one controlled before-after study, both from South Africa, evaluated this comparison.

 

  • Adding provider initiated HIV testing and counseling to sexually transmitted infection services probably increases the number of people receiving HIV testing. The certainty of this evidence is moderate.
  • Adding provider initiated HIV testing and counseling to TB services increases the number of people receiving HIV testing. The certainty of this evidence is high.

 

Adding on Provider Initiated HIV Testing and Counseling at primary health facilities compared to usual services

People          Facilities providing primary health services

Settings        STI and TB clinics in South Africa

Intervention Integration of Provider Initiated Testing and Counseling (PITC)

Comparison   Usual services

Outcomes

Absolute effect* (95% CI)*

Relative effect

(95% CI)

Number of
participants / sites

(studies)

Certainty

of the evidence

(GRADE)

Without the

addition of PITC

With the addition of PITC

 

Patients who received HIV testing in STI clinics  

475 per 1000

584 per 1000

(560 to 608)

RR 1.23

(1.18 to 1.28)

9080 patients at 21 primary care facilities

(1)

Moderate

New adult TB patients who received HIV testing in TB clinics 

65 per 1000

202 per 1000

(132 to 309)

RR 3.12

(2.04 to 4.77)

754 patients at 20 TB clinics

(1)

High

*The assumed risk WITHOUT the intervention is based on the control group of each study. The corresponding risk WITH the intervention is based on the overall relative effect.

CI: Confidence interval. RR: Relative risk. STI: sexually transmitted disease. TB: Tuberculosis. GRADE: GRADE Working Group grades of evidence (see above and last page)


3) Integration of services into routine primary care vs vertical delivery models for sexually transmitted infection services

One cluster randomised trial in Tanzania evaluated this comparison.

 

  • Integrating sexually transmitted infection services for female sexual partners of truck drivers into routine primary care may reduce women’s utilisation of these services and their attendance following referral. The certainty of this evidence is low.

 

Integration of sexually transmitted infection services compared to vertical delivery models of sexually transmitted infection services

People           Women living around truck stops, including female sexual partners of truck drivers

Settings         Truck stops and associated health facilities in Tanzania

Intervention  Integration of sexually transmitted infection services into routine health services open during normal working hours

Comparison   Vertical delivery models of sexually transmitted infection services, open after hours

Outcomes

Impact

 

Relative effect

(95% CI)

Number of
sites

(studies)

Certainty of the

evidence

(GRADE)

Utilisation of STI services by women

Integrating STI services into primary care may lead to lower utilisation

Not available

7 truck stops

(1)

Low

Women referred to and attended STI services

Integrating STI services into primary care may reduce referrals to and attendance of STI services

RR 0.54

(0.45 to 0.66)

7 truck stops

(1)

Low

CI: Confidence interval RR: Relative risk GRADE: GRADE Working Group grades of evidence (see above and last page)

STI: Sexually transmitted infection


4) Integration of HIV prevention and control at community and facility level vs government vertical service

One cluster randomised trial in Zimbabwe evaluated this comparison.

 

  • Integrated community and facility provision of HIV prevention and control improves the proportion of STIs treated effectively in males but leads to little or no difference in the proportion treated effectively in females. The certainty of this evidence is high.
  • Integrated community and facility provision of HIV prevention and control results in little or no difference in sexually transmitted disease incidence or HIV incidence in the population. The certainty of this evidence is high.

 

Integration of HIV prevention and control at community and facility level compared to usual government vertical service

People             People living in rural communities

Settings           Primary health services in Zimbabwe

Intervention    Integration of community (e.g. peer education and condom distribution) and facility (e.g. strengthened STI care)

services for the prevention and control of HIV, implemented jointly by non-governmental organisations and government health services

Comparison     Usual government vertical health service

Outcomes

Absolute effect* (95% CI)  

Relative effect

(95% CI)

Number of
participants

(studies)

Certainty

of the

evidence

(GRADE)

With usual services

With integrated services

 

STI treated effectively

- males 

559 per 1000

759 per 1000

(607 to 866)

POR 2.49

(1.22 to 5.10)

11980 adults

(1)

High

STI treated effectively

- females

686 per 1000

684 per 1000

(580 to 772)

POR 0.99

(0.63 to 1.55)

11980 adults

(1)

High

STI incidence

– males

42 per 1000

59 per 1000

(40 to 86)

POR 1.41

(0.94 to 2.12)

11980 adults

(1)

High

STI incidence

– females

149 per 1000

161 per 1000

(136 to 191)

POR 1.10

(0.90 to 1.35)

11980 adults

(1)

High

HIV incidence

1.49 per 1000 person years at risk

2.04 per 1000 person years at risk

IRR 1.27

(0.92 to 1.35)

11980 adults

(1)

High

CI: Confidence interval; STI: sexually transmitted infection; POR: prevalence odds ratio; IRR: incidence risk ratio. GRADE: GRADE Working Group grades of evidence (see above and last page)

* The risk WITHOUT the intervention is based on the median control group risk across studies. The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval).


 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All studies were conducted in low- and middle- income countries.

Many of the included studies focused on reproductive, maternal and child health.

 


Integration can be implemented across a wide range of primary care services. Evidence on effects across the full range of services and healthcare settings is not available.

The delivery of health services through vertical programmes or through integrated services is not mutually exclusive, and these approaches may be complementary in some settings and for some health issues.

The knowledge and skills of healthcare providers, the preferences of service users, the ways in which health services are governed and financed and the service delivery context must be taken into account before implementing integration policies in primary care.

Vertical programmes in low-income countries may be funded by international donor aid. This may need to be considered when attempting to integrate primary care services.


EQUITY
Integration of services may be implemented in order to reduce differences in access to and utilisation of health services between geographical and socio-economic groups. However, the review does not identify any information on this.

Integrated services that are targeted to specific underserved populations may improve equity. However, these interventions may have unintended and unwanted outcomes if they lead to:

- health workers being overloaded or deskilled

- a reduction in health workers’ ability and capacity to deliver specific technical services, compared to vertical programs.

- improved services for those with access to clinics and not for those without access to the clinics.

Where health systems are absent or very weak, vertical programmes may provide a mechanism for delivering basic technologies or services.


ECONOMIC CONSIDERATIONS
The studies in this review did not provide data on resource use or cost-effectiveness.

The integration of primary healthcare services requires extensive training, provision of necessary drugs and supplies and access to referral centres.

The cost-effectiveness and sustainability of integration policies are uncertain. Economic evaluations are needed and should be undertaken alongside implementation of these interventions.


MONITORING & EVALUATION
The review found some evidence regarding the effects of the integration of health services in primary care, but this evidence was mixed and very limited for some types of integration.

The impacts of integrating services should be evaluated before undertaking large-scale changes. Both intended outcomes and potential adverse effects should be monitored, guided by a logic model that provides a hypothesis of the relevant causal pathways.

‘Integration’ is a complex intervention and is understood in different ways in different settings. Evaluations therefore need to describe clearly the interventions being compared, including how services are integrated (or not) in practice, the extent to which this integration was implemented, and the support services that we needed.

Evaluations should include long-term follow-up of the impacts of integrating services.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see:
www.supportsummaries.org/methods


 

Additional information

Related literature

Atun RA, Bennett S, Duran A. Policy Brief. When do vertical (stand-alone) programmes have a place in health systems? Copenhagen: World Health Organization Regional Office for Europe, 2008. http://www.euro.who.int/document/hsm/5_hsc08_ePB_8.pdf

 

Butler M, Kane RL, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 09-E003. Rockville, MD. Agency for Healthcare Research and Quality. October 2008.

 

Church K, Mayhew SH. Integration of STI and HIV prevention, care, and treatment into family planning services: a review of the literature. Stud Fam Plann. 2009 Sep;40(3):171-86.

 

Mills A. Mass campaigns versus general health services: what have we learnt in 40 years about vertical versus horizontal approaches? Bull World Health Organ 2005; 83:315-6.

 

Wallace A, Dietz V, Cairns KL. Integration of immunization services with other health interventions in the developing world: what works and why? Systematic literature review. Trop Med Int Health. 2009 Jan;14(1):11-9.

 

This summary was prepared by

Cristian Herrera, Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad

Católica de Chile; Andy Oxman, Norwegian Institute of Public Health, Oslo, Norway; and and Shaun

Treweek, University of Aderdeen, United Kingdom.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Paul Garner and Natalie Leon.

 

This review should be cited as

Dudley L, Garner P. Strategies for integrating primary health services in low- and middle-income countries

at the point of delivery. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD003318.

 

The summary should be cited as

Herrera C, Oxman AD, Treweek S. Does integration of primary healthcare services improve healthcare delivery and outcomes? A SUPPORT Summary of a systematic review. April 2017.  www.supportsummaries.org

 

Keywords

Evidence-informed health policy, evidence-based, systematic review, health systems research,

health care, low and middle-income countries, developing countries, primary health care,

integrated delivery of health care.

 

This summary was prepared with additional support from:

 

 

The Health Policy and Systems Research Unit (UnIPSS) is a Chilean research collaboration for the generation, dissemination and synthesis of relevant knowledge about health policy and systems based at the School of Medicine of the P. Universidad Católica de Chile.



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