Landscape Analysis of Primary Healthcare Integration; Understanding Barriers and Enablers for People-Centered Care in Low-And-Middle Income Countries

Abstract

Background: Healthcare interventions in Low-and-Middle Income Countries (LMICs) are mostly disease-specific and exist independently, leading to fragmentation of services and inefficiencies in healthcare delivery. Therefore, the need to integrate interventions and share resources between programs is exigent. The dearth of evidence on the barriers and enablers for seamlessly integrated interventions in LMICs compared to high-income settings, necessitated the conduct of a landscape analysis of integration in LMICs to understand the extent of integration, barriers, and enablers for people-centered care in three countries – Nigeria, Nepal, and Madagascar. 
 Method: The study adopted a mixed-method approach involving a systematic review and qualitative study. Relevant literature and policy documents on healthcare integration in LMICs were reviewed. Also, 76 interviews (IDI and KII) were conducted with healthcare administrators at the national and local levels, healthcare workers, and caregivers in Nigeria, Madagascar, and Nepal. Content and thematic analyses of the systematic review and interviews were then conducted using Covidence software and Dedoose software respectively.
 Result: The result of the landscape analysis showed the different factors that impede health integration in LMICs include the inadequate number of the skilled health workforce, poor financing, inadequate supply of medicines and equipment, poor monitoring of policies and guidelines, poor supervision and M&E systems, and poor community engagement. To address these barriers, large investments in structural reforms must take place in these settings. From the policy landscape of the three countries, health integration of primary health care services is on the agenda of the health system as a priority. However, strong political will which is pivotal to monitoring the implementation of existing healthcare integration policies and advocating for sustainable funding opportunities from development partners will help to address the infrastructure deficits in the countries and subsequently help to promote integrated care. A key enabler for integrated care is community engagement; human-centered approach should be adopted from the program design phase to the implementation phase to ensure acceptance and uptake of integrated care especially when financial protection is not provided by the government.
 Implications for healthcare integration in LMICs: Integrated health services directly improve well-being and quality of life, which will bring important economic, social, and individual benefits. Integration has been proposed as a strategy to improve coverage and/or efficiency of immunization and other health programs. Therefore, to mitigate the bottlenecks to health integration in LMICs, efforts should be geared towards (i) building the capacity of health workers through training across all cadres. (ii) Government at all levels should recruit more staff to fill HRH gaps. (iii) Supervisory efforts should be increased as a key enabler to health integration. (iv) Provision of funds for healthcare integration in LMICs, and the development of a sustainable Financing plan (v) Strengthening supply chain support through investments in supplies, equipment, diagnostics, human resources, medicines, and commodities to support the provision of integrated services. (vi) Addressing the gaps and the design of integrated service delivery at the national and sub-national levels, considering feasibility, compatibility between the interventions, care plan needs, and goals of all stakeholders.