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Integrating healthcare services in low- and middle-income countries

Dudley L, Garner P
Published Online: 
6 July 2011

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.

This record 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. DOI: 10.1002/14651858.CD003318.pub3
Assessed as up to date: 
21 November 2010