Article type
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Abstract
Background: Over 30 years ago, integration of health programmes was first raised and was considered a way of achieving Health for All at Alma Ata. Now increasing concern with health system development, sector-wide approach and decentralisation has once again put integration at the foreground of current debates. Integration, however, remains a difficult concept to define uniformly, but is in general expected to improve efficiency of health service delivery.
Methods: This review summarised "case studies" obtained systematically to first define meanings and methods of integration, and second to document impacts measured. The inclusion criteria were: a. any intervention in a developing country aiming at integrating health services delivery at the first level of care; b. outcomes of at least one measure of effectiveness, efficiency or equity. Studies could be randomised, before and after studies or any other quasi-experimental or descriptive design.
Results: Few studies met the inclusion criteria. Of 13 studies reviewed, there were three before-and-after studies, two experimental studies, two post-test only control group design studies, and one randomised controlled trial. Seven of these studies took place in Africa, the other six in Asia. The majority of studies (10) were about integration in Maternal Child Health, one in sexually transmitted diseases and two interventions were multi-disciplinary. The results were variable: eight studies reported positive results, one reported marginally positive results, two reported an absence of impact and two studies reported negative results. Overall, there appears to be no strong evidence for the benefits of integration.
Discussion: The review raised several methodological issues, including: a. the difficulty defining what a term actually means in systems research; b. biases as many different changes are introduced at the same time; c. lack of clarity over purpose; d. the difficulty of measuring efficiency in studies of this kind; e. problems generalising management interventions.
Methods: This review summarised "case studies" obtained systematically to first define meanings and methods of integration, and second to document impacts measured. The inclusion criteria were: a. any intervention in a developing country aiming at integrating health services delivery at the first level of care; b. outcomes of at least one measure of effectiveness, efficiency or equity. Studies could be randomised, before and after studies or any other quasi-experimental or descriptive design.
Results: Few studies met the inclusion criteria. Of 13 studies reviewed, there were three before-and-after studies, two experimental studies, two post-test only control group design studies, and one randomised controlled trial. Seven of these studies took place in Africa, the other six in Asia. The majority of studies (10) were about integration in Maternal Child Health, one in sexually transmitted diseases and two interventions were multi-disciplinary. The results were variable: eight studies reported positive results, one reported marginally positive results, two reported an absence of impact and two studies reported negative results. Overall, there appears to be no strong evidence for the benefits of integration.
Discussion: The review raised several methodological issues, including: a. the difficulty defining what a term actually means in systems research; b. biases as many different changes are introduced at the same time; c. lack of clarity over purpose; d. the difficulty of measuring efficiency in studies of this kind; e. problems generalising management interventions.