ReviewIntegrated care for people with long-term mental and physical health conditions in low-income and middle-income countries
Introduction
The global pattern of the burden of disease is changing.1, 2 Health-care systems, which traditionally focused on acute care, are now increasingly needing to address the challenge of providing care for people with chronic conditions. These changes offer an opportunity to integrate mental and physical health care to address the full range of health-care needs of the whole person.
The term chronic conditions refers to a range of disorders, either communicable (eg, HIV and AIDS, or tuberculosis) or non-communicable (eg, cardiovascular disease, cancer, diabetes, depression, or alcohol-use disorders), characterised by long duration (at least 3 months), remitting and recurring symptoms, and often slow progression. Such chronic conditions frequently include comorbid physical and mental disorders.
In 2016, WHO described a bold vision for integrated care, defining it as “health services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector, and according to their needs throughout the life course”.3
In this Review, we aim to describe the most relevant concepts and models of integrated care for people with severe mental illness and co-occurring chronic physical conditions, to assess the strength of the evidence base for these models in high-income countries and in low-income and middle-income countries (LMICs), and to identify priorities to test the feasibility and effects of such integrated care models in LMICs in the future.
Section snippets
Rationale for integrating care for people with severe mental disorders into chronic care
The health and social consequences of long-term physical and mental disorders are increasingly recognised as major concerns for health, as well as for social and economic development. Life expectancy has considerably improved in most parts of the world in recent decades: globally, life expectancy from birth has increased from 61·7 years (95% uncertainty interval 61·4–61·9) in 1980 to 71·8 years (71·5–72·2) in 2015,1 reflecting a global transition from the burden of infectious diseases on public
Methods
In this review, we identified few review papers related to the effectiveness of chronic care models in LMICs, defined using World Bank Country Group criteria. Therefore, we did a structured, narrative literature review to address the question of what evidence exists from LMICs for implementing the chronic care model or ICCCF and improves processes and clinical outcomes for people with long-term mental disorders and comorbid physical disorders, for family and household members, and for health
Overview
Figure 2 shows the step-wise results of the literature search procedure. A total of 21 documents (18 papers and three book chapters) were included in the final Review46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66 (appendix). The inter-rater reliability (κ) between reviewers was 0·80.
Study design of reviewed papers
Of the 21 documents included, two were randomised controlled trials, nine were cross-sectional studies, two were systematic reviews, and the remaining eight were descriptive or
Key organisational challenges to the implementation of integrated chronic care in LMICs
The findings from this narrative review of studies of integrated care in LMICs are fully aligned with the results of our conceptual overview of this field. Both sources confirm that health systems are poorly configured to deal with chronic care needs, as has been shown by the Disease Control Priorities mental health group.76 These key findings can be presented according to the WHO health systems building blocks.19
Governance is described by WHO as the steering and rule-making functions of
Conclusions
We have presented the results of a conceptual overview and a narrative review of integrated care for people with chronic mental disorders and comorbid chronic physical conditions, examined the evidence that this approach produces benefit, identified barriers that limit such implementation, and proposed actions to better integrate care in future, particularly in LMICs. Such changes are not trivial, and might require fundamentally restructuring health-care provision, which in many countries is
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