Introduction:
Achieving universal health coverage (UHC) has gained wide acceptance and is considered a key health policy goal in many countries. In the Philippines, a national legislation on UHC served as an overarching policy for implementing sector-wide health reforms. Central to the process is the concept of health systems integration which policymakers look toward as a means to address longstanding fragmentation in health. The underlying push is the belief that bringing together of inputs, delivery, management, and organization of services in an integrated manner will improve access, efficiency, and quality of health services. Experience from other countries shows that the road to UHC is inextricably linked to the complex process by which policy decisions take place - one that is fraught with challenges, diverse pathways, and pitfalls. To jumpstart the reform, inter-LGU cooperation was the main governance mechanism that was proposed.

Methods:
A descriptive and explorative case comparison methodology was used involving three individual case studies followed by a cross-case analysis for the selected study sites. The study aims to understand the socio-economic and political underpinnings, consensus-building process, and integration pathways using Bosserts decision space framework. We synthesize the findings to identify issues and challenges associated with inter-LGU cooperation and its implication on governance in integrated health systems.

Findings:
Results show that there was no uniform conceptual model for local health systems integration across the study sites. Local health systems resort to implementing cooperative models that are contextually appropriate based on local evidence and competence. However, potential diverging interests of cooperating LGUs were observed to have created collective action problems resulting in large inefficiencies termed as wicked problems. The study offers evidence for comparing experiences in other settings. It is also imperative that the identified wicked problems be further explored to understand their mechanism and impact on health systems performance