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What Is Service Integration In Primary Health Care

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Characteristics of Indigenous primary health care service delivery models: a systematic scoping review

  • Carol Davy1,2,
  • Alexa McArthuriii,
  • Zachary Munnthree,
  • Alex Brownane,4 &
  • Ngiare Brown1,5

Globalization and Wellness book 14, Article number:12 (2018) Cite this commodity

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This article has been updated

Abstruse

Background

Indigenous populations have poorer health outcomes compared to their not-Indigenous counterparts. The evolution of Indigenous primary health intendance services arose from mainstream health services beingness unable to adequately come across the needs of Indigenous communities and Indigenous peoples often being excluded and marginalised from mainstream health services. Part of the solution has been to establish Indigenous specific primary health care services, for and managed by Indigenous peoples. In that location are a number of reasons why Indigenous primary wellness care services are more likely than mainstream services to improve the health of Indigenous communities. Their success is partly due to the fact that they often provide comprehensive programs that incorporate treatment and direction, prevention and health promotion, as well equally addressing the social determinants of health. However, there are gaps in the evidence base including the characteristics that contribute to the success of Indigenous primary health care services in providing comprehensive primary health care. This systematic scoping review aims to place the characteristics of Indigenous primary health care service delivery models.

Method

This systematic scoping review was led by an Aboriginal researcher, using the Joanna Briggs Found Scoping Review Methodology. All published peer-reviewed and greyness literature indexed in PubMed, EBSCO CINAHL, Embase, Informit, Mednar, and Trove databases from September 1978 to May 2015 were reviewed for inclusion. Studies were included if they describe the characteristics of service delivery models implemented within an Indigenous primary health care service. Sixty-two studies met the inclusion criteria. Information were extracted and then thematically analysed to place the characteristics of Indigenous PHC service delivery models.

Results

Culture was the most prominent feature underpinning all of the other 7 characteristics which were identified – accessible wellness services, customs participation, continuous quality improvement, culturally appropriate and skilled workforce, flexible approach to care, holistic health care, and self-determination and empowerment.

Conclusion

While the eight characteristics were conspicuously distinguishable within the review, the interdependence betwixt each characteristic was also evident. These findings were used to develop a new Indigenous PHC Service Commitment Model, which clearly demonstrates some of the unique characteristics of Indigenous specific models.

Groundwork

Indigenous populations have poorer health outcomes compared to their not-Indigenous counterparts [1]. The experience of colonisation, and the long-term effects of being colonised, has caused inequalities in Ethnic health condition, including physical, social, emotional, and mental wellness and wellbeing [ii]. For example, in 2012 the gap in life expectancy between Aboriginal and Torres Strait Islander Australians and not-Ethnic Australians was ten years [3]. Similar gaps in life expectancy exist in New Zealand [4], Canada [5] and the United States [vi].

The development of Indigenous primary health intendance (PHC) services arose from the inability of mainstream wellness services to adequately meet the needs of Ethnic communities [3, 7, 8]. It was too a response to the reality that Ethnic peoples were frequently excluded and marginalised from mainstream health services [9]. Part of the solution has been to plant Indigenous specific PHC services, for and managed by Indigenous peoples.

In Australia, the first Aboriginal PHC service was established in 1971 [nine] and there are now over 150 Aboriginal Community Controlled Health services across the country [x]. In New Zealand, health reform in the early 1990's led to the development of Māori health providers. This has resulted in a combination of national and locally controlled Māori led initiatives that are committed to improving Māori health [vii]. In Canada, the enactment of the Health Transfer Policy in the late 1980'southward initiated the transfer of existing community-based and regional wellness services into First Nation and Inuit control [eleven, 12], and more than recently the establishment of Kickoff Nations and Inuit Health Authorities [13]. In the United States, the provision of health services for American Indians and Alaska Natives began as early on as the nineteenth Century and continued through the 1930's, 1950'due south and 1970's with a number of policy reforms, culminating in what is at present known every bit the Indian Health Services [14,xv,xvi].

There are a number of reasons why Indigenous PHC services are more likely than mainstream services to ameliorate the health of Indigenous communities. I of the chief reasons is that Indigenous PHC services are ofttimes controlled by their local communities [7, xiii, xiv, 17] and therefore are underpinned by the values and principles of the communities they serve [eighteen]. Their success is also due to the fact that they ofttimes provide comprehensive programs that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health [14].

Despite their success, there are gaps in the bear witness base including the characteristics that contribute to the success of Indigenous PHC services in providing comprehensive PHC. This systematic scoping review sought to address this gap past identifying the characteristics (values, principles, and components) of Indigenous PHC service delivery models.

Method

In 2015, the Leadership Group as part of The Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Commutation, identified the need to document the characteristics of Ethnic PHC service delivery models. Guided by the Leadership Group, a review squad was formed comprising ane Ancient [SH] and three non-Indigenous researchers [CD, AM, ZM]. A central feature of this review was the combination of perspective and skills that the Leadership Group and the researchers brought to the project. This included expertise in systematic and scoping reviews besides as an agreement of Indigenous beliefs, values and experiences.

A scoping review methodology was chosen, equally it is the near appropriate methodology for synthesising a body of show that has however to be comprehensively reviewed [nineteen]. Additionally, scoping review methodology is acknowledged as advisable method to identify concepts or characteristics in the literature [19], such as the characteristics of Ethnic PHC service delivery models. This systematic scoping review followed the Joanna Briggs Institute Scoping Review Methodology [20]. The review squad developed and published a protocol prior to commencing the systematic scoping review [21], that outlined the intended arroyo and method, which is summarised beneath.

Inclusion criteria

Concept – the characteristics (values, principles, and components) of service delivery models implemented within an Indigenous PHC service.

Context – PHC services that provided intendance predominantly for Indigenous peoples.

Indigenous peoples were defined as:

Indigenous populations are communities that live within, or are attached to, geographically distinct traditional habitats or ancestral territories, and who place themselves equally being part of a singled-out cultural group, descended from groups present in the area before mod states were created and electric current borders defined. They generally maintain cultural and social identities, and social, economic, cultural and political institutions, separate from the mainstream or ascendant order or culture ([22](para. 1)).

Master wellness care was defined every bit:

socially appropriate, universally accessible, scientifically sound outset level care provided by health services and systems with a suitably trained workforce comprised of multi-disciplinary teams supported by integrated referral systems in a manner that: gives priority to those almost in need and addresses wellness inequalities; maximises community and individual self-reliance, participation and control; and involves collaboration and partnership with other sectors to promote public health. Comprehensive primary health intendance includes wellness promotion, illness prevention, treatment and care of the sick, community development, and advocacy and rehabilitation ([23](para. iii)).

The to a higher place definitions ensured all reviewers shared the same understanding of Indigenous and PHC and all included studies met the inclusion criteria.

Types of studies

All report types and methods including grey (unpublished) literature published in English betwixt September 1978 and May 2015 were considered. Given that the concept of PHC was broadly adopted in September 1978 [24], papers prior to this date were excluded.

Search terms

Aboriginal OR Aborigine OR Ethnic OR First Nation OR Maori OR Inuit OR American Indian OR Alaskan Native OR Native Hawaiian AND primary health care OR comprehensive primary health care OR medical service OR health service OR community intendance OR customs wellness care AND model.

Search strategy

An initial search of PubMed was conducted to identify text words contained in the title and abstruse besides as any index terms that could be used as alternate search terms. A second, more detailed search was then undertaken using the identified search terms beyond PubMed, EBSCO CINAHL, Embase, Informit, Mednar, and Trove. The detailed search strategy used for PubMed, which is the basis for all other databases searched tin exist found in Additional file 1. The reference list of all identified studies were also hand-searched for additional studies which met the inclusion criteria. As a last step, a post was placed on ResearchGate to place any additional literature (particularly grey literature) which may not accept been widely bachelor through conventional databases.

Study selection

The selection of studies was performed by four of the authors [SH, CD, AM, ZM] over two stages – title and abstract review; and total text review, against the inclusion criteria. During the 2 stages of written report selection, writer one [SH] reviewed all studies and this was checked by either one of the other three authors [CD, AM, ZM]. Whatsoever disagreements were discussed and resolved by authors.

Charting of data

All papers were imported into QSR International's NVivo 10 software [25] for extraction of reported characteristics. This assay was initially conducted independently by the four authors [SH, CD, AM, ZM]; [SH] checked the data extraction and assay of the three other authors [CD, AM, ZM], while a combination of the other authors checked the data extraction and analysis initially conducted by [SH]. Any disagreements were discussed and resolved betwixt the 4 authors. Thematic analysis was used to grouping the extracted findings into characteristics. Findings were reviewed by members of the Leadership Group on two split up occasions during the synthesis process in order to provide an Ancient and Torres Strait Islander perspective on their validity.

Results

The original search identified 2599 studies (Fig. one), from which 402 duplicates were removed, leaving 2197 studies for screening of title and abstract against the inclusion criteria. From this we retrieved 141 studies for total text review, of these 62 met the inclusion criteria (Additional file 2). Study selection follows the PRISMA reporting guidelines for report selection [26].

Fig. 1
figure 1

Menstruation chart of study selection for scoping review process

Total size image

Description of studies

The bulk of studies included in the review were conducted in Australia [27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58], 18 studies were conducted in the United States [59,threescore,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76], five in Canada [77,78,79,80,81], four studies in New Zealand [82,83,84,85] and one study each in Papua New Republic of guinea [86], Mexico [87] and Peru [88]. Of the studies included, the majority of service delivery models focused on PHC service commitment more than mostly [29,30,31,32, 34, 36, 40,41,42, 49, 52,53,54, 56, 58, 61, 64, 66, 67, 69, 71, 73, 75, 76, 81, 82, 84,85,86]; while the others studies focused on specific areas such as women's, maternal and infant health [27, 45, 47, 57, sixty, 78, 79, 87, 88]; mental health [70, 78, 80]; oral health [33, 39, 65]; eye wellness [62, 77]; adult wellness [38]; prevention and health promotion [63, 72, 74]; public and environmental health [59]; homecare [68]; prison health [l, 51, 55]; asthma [35, 37]; diabetes [83]; alcohol and other drugs [46]; medicine access [89]; and continuous quality comeback [28, 43].

Characteristics

Of the included studies, 8 characteristics of Indigenous PHC service delivery models were identified – accessible health services, community participation, continuous quality improvement, culturally appropriate and skilled workforce, culture, flexible approach to care, holistic health care, and cocky-determination and empowerment. These characteristics underpin many of the service delivery models in this review.

While civilization was initially thought to be one of the eight characteristics identified, it became evident through the procedure of thematic assay, that information technology played a central part and was embedded throughout all Indigenous PHC service commitment models. Although the studies did not provide a definition of civilization in the context of Indigenous PHC services, they did even so demonstrate how aspects of culture were embedded within services and how culture is respected.

Pivotal strategies for embedding culture included the incorporation of local Indigenous cultural values [30, 54, 69, 73, 82]; customs and beliefs [38, 53, 75, 77, 79, 80, 82, 85, 88], likewise as traditional healing and practices [36, 77, 79] into the service delivery model. Focusing on the needs of the individual and on the health and wellbeing of their families and communities [33, 34, 85]; respecting women's and men'south cultural needs [38, 41, 45, 72, 87], such as women just discussing women's health business with other women [45] or gender specific services and programs [41, 72, 87]; and ensuring the local communities were engaged with [40, 85] and in control of, Ethnic health services, [52, 79, 85] were ways in which culture was embedded into service delivery models and ensured the delivery of culturally advisable care and made services more acceptable to Indigenous communities. Other practical examples of how culturally appropriate service commitment was achieved, included creating welcoming [41] and comfy spaces [72], and family unit-friendly environments [48, 85], through to for example, the use of Ethnic artwork and Ethnic signage [27], and developing culturally appropriate prevention and health promotion resources [37, l, 63, 72].

Culture was strengthened in many instances by ensuring local languages were spoken inside the service [38, 41, 61, 72, 77, 80, 87, 88]. This was often achieved through the employment of local Indigenous staff who too acted as interpreters for non-Indigenous health staff [81]. The employment of local Ethnic staff also incorporated aspects of cultural mentoring [38, 45, 81] ensuring not-Indigenous staff were culturally competent [45, 84] and enlightened of local protocols and values [58]. This contributed to ensuring cultural condom, a concept which extended beyond existence simply enlightened of cultural differences to incorporating a deeper level of interaction and thoughtful do, every bit defined by those who receive services [38, 47, 48, 50, 52, 56, 66, 79].

The other seven characteristics of Indigenous PHC service commitment models are described in Table i.

Table 1 Characteristics of indigenous PHC service delivery models

Total size table

While each of these characteristics were clearly identifiable as contained themes within the literature, the interdependence between characteristics was too evident. As mentioned, civilisation was interwoven throughout the seven other characteristics. Civilization facilitated assessable health services, informing the commitment of culturally appropriate services by making them acceptable by the community [34, 47, 54, 58, 74, 80, 82, 87]. Culture was critical to ensuring community participation, enabling Indigenous ownership and governance by engaging communities [thirty,31,32, 34, 35, 40, 60, 61, 64, 70, 82], and engaging in quality improvement process and defining outcomes and indicators [64]. Culture was of import in ensuring the arroyo to care is culturally appropriate and relevant [36, 82, 83], and holistic including comprehensive and providing a various range of intendance, which included traditional healing [36, 52, 59, 63, 64, lxx, 72, 73, 77, 79,80,81,82, 84,85,86,87,88]. Civilisation informed and supported the philosophy underpinning Indigenous self-decision, particularly community participation, ensuring Ethnic peoples having the right and determination to decide how their PHC services should, and can be delivered [30, 33, 40, 49, 59, 69, 73, 82, 85].

Another case of interdependence between characteristics is culturally advisable and skilled workforce, which was an enabler for culture, holistic health care and accessible health services. Employing local Indigenous staff helped to embed community cultural values, community and behavior into service delivery [45, 77, 78, 81]. Workforce was central to the delivery of services, providing a holistic comprehensive PHC and a diverse range of care [38, 52, 83, 85, 87, 88]. A culturally appropriate and skilled workforce too enabled services to be accessible and acceptable, past building trust with communities [45, 83, 87], ensuring patients felt supported [38, 41], providing assurances in relation to privacy and confidentiality [38, 80], and implementing services underpinned by cultural respect, social justice and equality [47].

As a result of identifying the characteristics of Indigenous PHC service delivery models, we have identified and described a new Indigenous PHC Service Commitment Model, equally depicted in Fig. 2. Fundamental to this model is culture, as previously discussed civilization plays a central function in Ethnic PHC service delivery models; and is encompassed by the seven other characteristics – accessible wellness services, community participation, continuous quality improvement, culturally appropriate and skilled workforce, flexible approach to care, holistic health intendance, and self-determination and empowerment. While Tabular array one provides details every bit to how the characteristics have been embedded throughout other Indigenous PHC service commitment models, they as well act as examples of how the characteristics of the Indigenous PHC Service Delivery Model can be implemented inside other services.

Fig. two
figure 2

Characteristics of Ethnic Chief Health Care Service Delivery Model

Full size prototype

Discussion

The aim of this scoping review was to place the characteristics of Indigenous PHC service delivery models. We found that culture underpinned all aspects of the Ethnic PHC service delivery models identified in this review. In addition, nosotros identified vii other distinct characteristics of Ethnic PHC service delivery models – accessible health services, customs participation, continuous quality improvement, culturally advisable and skilled workforce, flexible approach to care, holistic health care, and self-decision and empowerment.

These findings suggest that Indigenous PHC service delivery models are somewhat different to many of the models of intendance developed within western contexts. For example, the Chronic Care Model [90] focuses on implementing evidence based intendance, mobilising community resource, enabling patient'southward self-management, and ensuring coordinated intendance and wellness promotion. The explicit role of culture in the provision of services is notably absent from this model. Culture is also notably absent-minded from the World Wellness System Innovative Care for Chronic Weather Framework [91] and the Southgate Model of Comprehensive Principal Health Care in Australia model [92].

By contrast, it is evident that local cultural values, customs and beliefs were at the centre of and underpinned all aspects of care in Indigenous PHC service commitment models. This was a common thread in the majority of the studies included in this scoping review. The role of culture as a defining feature, therefore, provides the greatest distinction between Ethnic PHC service delivery and other models of intendance. This is consequent with the growing literature on culture and wellness, which describes the importance of culture and its result on wellness and wellbeing [2, 93,94,95], including in non-Indigenous populations [96]. These are potential lessons mainstream wellness care services could learn from in order to make their services more culturally condom and advisable to Indigenous peoples. Three characteristics stand out every bit distinctive aspects of Ethnic PHC service commitment models. These are culturally appropriate and skilled workforce; community participation; and self-decision and empowerment. At the heart of a culturally advisable and skilled workforce were the Indigenous staff. This supports the belief that Indigenous PHC services are best delivered by Indigenous peoples [17]. In particular, employing local Ethnic staff helps to embed the community's cultural values, customs and behavior into service delivery. Indigenous peoples providing health care to their own people has been shown to improve wellness outcomes related to diabetes [97], asthma [98], mental health and maternal and infant care [99]. Chiefly, local Indigenous staff provide more adequate care [100], likewise as encouraging access to PHC more than generally [101]. One of the many challenges faced past Indigenous PHC services is the need to maintain current levels of Indigenous staff, while at the same time, growing their Ethnic health workforce [66, lxxx]. This requires a partnership between Ethnic PHC services and governments to ensure the growth of the sector is done in a manner that is meaningful and culturally safe.

Community participation was establish to exist particularly important for ensuring Indigenous PHC services go on to identify, understand and address the needs of local Indigenous peoples. Customs participation likewise facilitated Indigenous governance and ownership. One example is the Southcentral Foundation in Anchorage Alaska, it is peradventure ane of the most well-known Indigenous models of care (four of the included studies are from the Southcentral foundation [lx, 64, 69, 76]). The success of this model, including significant improvements in health outcomes is associated with the notion of 'customer-owners' ([102] p. one). The model ensures that Alaska Native people are in control of their wellness service and the human relationship that is built and maintained by the service with its 'client-owners' ([102] p. 1). Many of these services included in this review were too underpinned by the philosophy that Indigenous peoples having the right to decide how their PHC services should be developed and delivered. Aboriginal Community Controlled Health Organisations in Australia have been identified as exemplars of these types of community governance models [103], further demonstrating the link between community control and positive health outcomes.

Self-determination and empowerment were the driving principles behind the institution of many Indigenous PHC services included in this review. Indigenous PHC services facilitated a number of opportunities for self-conclusion and empowerment. These include ensuring that Indigenous peoples are able to take control of their own health service; the employment and preparation of Indigenous peoples; and just as importantly community development initiatives such equally cultural days and camps, and reconciliation events. Previous studies have demonstrated an association between empowerment of Ethnic peoples and communities and meliorate wellness outcomes for Indigenous peoples [104, 105]. As on example, a systematic review conducted by Minichiello et al. [106], found that tobacco intervention programs which had elements of self-determination and were relevant to the customs were more likely to lead to positive outcomes such every bit reduced initiation and consumption of tobacco. Often self-determination and empowerment are associated with customs participation. Community participation and mobilization in wellness intendance is essential for ensuring services can identify health needs and gear up priorities, plan, implement, monitor and evaluate services and programs, this is consequent with existing literature on community participation in wellness [107].

Indigenous PHC service delivery models are exceptional models of PHC, delivering health intendance to Ethnic peoples and communities across the world, often to isolated populations or communities where no other service delivery model is viable. While at that place are numerous benefits to Indigenous PHC service delivery models, at that place are also limitations: Indigenous PHC service delivery models practise non align with regime funding mechanism [108, 109]; at that place is often a lack of funding to back up specific Indigenous PHC services [108,109,110]; the demand for services outweighs funding and the availability of services [108,109,110]; and the commitment of wellness care to Indigenous peoples is more expensive [108, 109].

Policies need to acknowledge and have into account the differences between Indigenous PHC models of care and other PHC models of care. This is particularly crucial when it comes to the funding of Ethnic PHC services, as the lack of sufficient funding together with the doubt that comes from short-term funding models led to the inability of services included in this review to back up the unique characteristics of Indigenous PHC services [27, 32, 33, 40, 51, 54, 78, 82]. Funding models are one of the fundamental drivers for how care is provided [111]. Nevertheless it is too the case that until Ethnic PHC service delivery models are conspicuously articulated, policy makers will not be able to blueprint appropriate funding mechanisms to back up the way in which they provide intendance. We believe that the Indigenous PHC service delivery characteristics identified by this scoping review is one pace towards making Ethnic PHC service delivery models explicit.

While this is the beginning review of its type to identify the characteristics of Ethnic PHC service delivery models, a review by Lewis and Myhra on Integrated care with Indigenous populations: a systematic review of the literature [112], was identified. Withal, that review focused on assessing how health care services are conceptualising and enacting integrated care with American Indian and Showtime Nations populations in the U.s.a. and Canada and the successes and challenges of carrying out these interventions with this population. It identified the motivations for integration and its effectiveness. Our review was more inclusive of health services and Ethnic populations from beyond the global and focused on the characteristics of Ethnic PHC service commitment models rather than the motivations of one particular service commitment model.

Conclusion

Ethnic PHC services evolved as a result of mainstream wellness services inability to encounter the needs of Indigenous peoples [3, 7, eight] and Ethnic peoples often being excluded and marginalised from mainstream health services [9]. In add-on, Indigenous communities wanted to be able to provide care to their communities that is culturally appropriate, comprehensive, holistic, attainable, and community controlled. The review identified 8 characteristics of Indigenous PHC service delivery models. These characteristics were found to exist global in their awarding, and provide insight and guidance to communities and organisations wishing to initiate an Indigenous PHC service and programs. The review besides affirms and supports the philosophy underpinning Ethnic self-determination, particularly Ethnic peoples having the right and determination to make up one's mind how their PHC services should be and can be delivered for themselves. If communities and governments are genuinely serious about endmost the gaps in life expectancy and morbidity betwixt Ethnic and non-Indigenous peoples, and so Indigenous PHC services must keep to exist supported.

Change history

  • xvi Feb 2022

    Following the original publication of this article, the corresponding author has updated their email address from norbertfbecker@spider web.de to s.harfield@uq.edu.au; they no longer piece of work for the institution associated with the former accost.

Abbreviations

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Acknowledgements

The authors would like to give thanks the Center of Research Excellence in Aboriginal Chronic Illness Knowledge Translation and Exchange Leadership Grouping for their guidance and support; Assoc Prof James Ward (Infection and Amnesty, South Australian Health and Medical Research Institute), Dr. Odette Gibson (Wardliparingga Research Unit, South Australian Health and Medical Research Establish) and Prof Annette Braunack-Mayer (School of Public Health, The University of Adelaide) for their comments on the last draft; and Eliza Cobb, (Marketing and Communications, South Australian Health and Medical Research Institute) for your graphic design skills.

Funding

This research was supported past National Wellness and Medical Research Council (NHMRC No 1061242).

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Not applicative.

Authors' contributions

NB, AB contributed to the conceptualisation of the review. SH, CD, AM and ZM designed the search strategy, were involved with study selection and review, analysis of data and drafting of manuscript. SH conducted the search. All authors reviewed and canonical the final manuscript.

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Affiliations

  1. Wardliparingga Aboriginal Wellness Inquiry Unit, South Australian Health and Medical Enquiry Plant, Adelaide, South Australia, Australia

    Stephen G. Harfield, Carol Davy, Alex Brown & Ngiare Brown

  2. School of Public Wellness, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia

    Stephen 1000. Harfield & Carol Davy

  3. Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Adelaide, Due south Australia, Australia

    Alexa McArthur & Zachary Munn

  4. Sansom Institute for Health Research, University of Due south Australia, Adelaide, South Commonwealth of australia, Commonwealth of australia

    Stephen 1000. Harfield & Alex Brown

  5. School of Education and Schoolhouse of Medicine, University of Wollongong, Wollongong, NSW, Australia

    Ngiare Dark-brown

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Correspondence to Stephen One thousand. Harfield.

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Harfield, S.One thousand., Davy, C., McArthur, A. et al. Characteristics of Indigenous chief health care service delivery models: a systematic scoping review. Global Health 14, 12 (2018). https://doi.org/x.1186/s12992-018-0332-2

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Keywords

  • Primary health care
  • Models of care
  • Service commitment
  • Ethnic
  • Aboriginal and Torres Strait Islander
  • American Indian and Alaska Native

What Is Service Integration In Primary Health Care,

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