Integrated primary health care in low- and middle-income countries: a double challenge

The lack of primary healthcare integration has been identified as one of the main limits to programs' efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges to be met for its achievement: 1) developing a "crosswise approach" to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors.

The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project (2011-2014) evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions.

In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions.