August 2008 – SUPPORT Summary of a systematic review

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

Who is this summary for? People deciding whether to integrate primary healthcare services.

This summary includes: − Key findings from research based on a systematic review − Considerations about the relevance of this research for low and middleincome countries

Not included: Primary health care in many low and middle-income countries is organised through a series of vertical programmes for specific health problems such as tuberculosis control or immunisation of children. Vertical programmes can help deliver particular technologies, but may lead to service duplication, inefficiency and service fragmentation. The World Health Organization and other organizations promote integration, where inputs, delivery, management and organization of particular service functions are brought together, as a solution to such problems.

Key messages 

What integration means in practice is not always clear. There are a number of strategies for integrating primary healthcare services at the point of delivery, including simply adding on services, bringing together the delivery of existing services, and implementation of packages of services.

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There is limited evidence of the effects of alternative strategies from comparisons between integrated and vertical approaches to delivering services.

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Integrated Management of Childhood Illness appears promising, but co-interventions, including provision of drugs, may confound this.

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Integration may not, in reality, improve service delivery and outcomes, including evolving strategies for implementing and sustaining Integrated Management of Childhood Illness. If strategies to achieve integration are used, their impact should be evaluated.

− Recommendations − Additional evidence not included in the systematic review − Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review: Briggs CJ, 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.

What is a systematic review? A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies. SUPPORT – an international collaboration funded by the EU 6th Framework Programme to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low and middle-income countries. www.support-collaboration.org Glossary of terms used in this report: www.supportcollaboration.org/summaries/explanat ions.htm Background references on this topic: See back page

How this summary was prepared

Background In many low and middle-income countries, certain government health services 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 (including, for example, HIV/AIDS or malaria prevention). Specialized, separate, vertical programmes allow central technical supervision to ‘reach out’ through self-contained vertical programmes. The advantage of this approach to delivering care is assumed to be that it can better assure the delivery of services within the particular programme. Vertical programmes, however, can also lead to service duplication, inefficiency and service fragmentation. Integration of primary health care 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.

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low and middle-income countries. The methods used to assess the quality of the review and to make judgements about its relevance are described here: http://www.supportcollaboration.org/summaries/meth ods.htm

Knowing what’s not known is important A good quality review might not find any studies from low and middleincome countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

About the systematic review underlying this summary Review objective: To assess the effects of strategies to integrate primary healthcare services What the review authors searched for

What the review authors found

Interventions

Any management or organizational change strategy applied to existing systems that aimed to increase integration at the service delivery level in primary health care

- Integrated Management of Childhood Illness (2 studies) - Adding a family planning clinic to an expanded program of immunisation (1 study) - Family planning through an integrated maternal and child health service versus a dedicated family planning service (1 study)

Participants

Primary healthcare facilities in low and middle-income countries

Two studies focused on childhood illness and three on family planning

Settings

Primary healthcare facilities in low and middle-income countries

Bangladesh, Tanzania (2 studies), Togo, Nepal

Outcomes

Healthcare delivery Health status Acceptability Intermediary outcomes

Healthcare delivery (4 studies) Health status (3 studies) Acceptability (2 studies) Intermediary outcomes (4 studies)

Date of most recent search: September 2005 Limitations: This is a good quality systematic review with only minor limitations. Briggs CJ, 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.

Background

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Summary of findings The studies identified fell into three categories: packaging of enhanced primary child care services (Integrated Management of Childhood Illness), service add-on, and integrated services versus single special services.

About quality of evidence (GRADE) High: Further research is very unlikely to change our confidence in the estimate of effect.

1) Packaging of enhanced primary child care services versus routine child care (Integrated Management of Childhood Illness)

Moderate: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Two studies included in this review evaluated Integrated Management of Childhood Illness compared with routine services. One was a cluster-randomised trial of 20 first level outpatient clinics and their catchment areas in Bangladesh. The study reported a number of improvements in healthcare delivery, which are summarised in the table below.

Low: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

The second study was a controlled before-after investigation of two selected districts in Tanzania. It, too, reported improvements in healthcare delivery, although the quality of this evidence is very low given the study design that was used, that there was only one district in each group and assessments of outcomes were not blinded to the intervention. It found that more children attending health facilities were checked for cough, fever and diarrhoea and correctly classified at intervention facilities. More supervisory visits to facilities occurred in the intervention group. The costs of child health care (which included some of the training costs of Integrated Management of Childhood Illness) were similar between the two groups. Child mortality was similar in the two areas at the start of the study, but fell in the Integrated Management of Childhood Illness group (a 13% reduction, with 95% CI of -7 to +30%). 

Very low: We are very uncertain about the estimate. For more information, see last page.

Integrated Management of Childhood Illness appears promising, but co-interventions, including provision of drugs, may confound this.

Summary of findings

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Does Integrated Management of Childhood Illness improve the delivery of primary health care compared to usual care?* Patients or population: Outpatient clinics Settings: Bangladesh Intervention: Integrated Management of Childhood Illness Comparison: Routine care (without Integrated Management of Childhood Illness) Outcomes

Comparative risks

Index of correct assessment

Without Integrated Management of Childhood Illness

With Integrated Management of Childhood Illness

Mean 17

Mean difference +56

Relative effect

Number of studies

Quality of the evidence (GRADE)

1 study‡ Moderate

(p