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


OBJECTIVE
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.


METHODS
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.


METHODS
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.


METHODS
Two authors independently extracted data and assessed study quality.


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.


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.
Briggs
C J
CJ
Management Sciences for Health, Center for Pharmaceutical Management, 4301 North Fairfax Drive, Suite 400, Arlington,Virginia 22203-1627, USA. jbriggs@msh.org
Garner
P
P
D002648:Child; D002662:Child Health Services / Q000458:organization & administration; D002986:Clinical Trials as Topic; D019033:Delivery of Health Care, Integrated; D003906:Developing Countries; D005193:Family Planning Services / Q000458:organization & administration; D017048:Health Care Costs; D006801:Humans; D017063:Outcome Assessment, Health Care; D011320:Primary Health Care / Q000458:organization & administration*; D012749:Sexually Transmitted Diseases / Q000517:prevention & control