The fact that health policies exist does not automatically mean that a country also has effective health programmes in operation.  There is a lack of sustained, properly-functioning programmes that focus on the prevention and treatment of syphilis during pregnancy. In a number of countries, many women are not being screened. Problems exist because of a lack of user and provider involvement in the design stages before implementation.

Researchers from the London School of Hygiene and Tropical Medicine suggest that the low number of women being screened for antenatal syphilis is not due to a lack of policies, high financial costs or technical difficulties.  On the contrary, many countries have:

• national screening policies
• simple and effective screening tools exist
• cheap and readily available penicillin needed to treat the condition.

The researchers suggest that the low priority given to antenatal syphilis treatment and prevention is the result of a failure to consider the views of all stakeholder groups (providers, policy-makers and users) when programmes are designed.  They examine existing evidence on the understanding and awareness of syphilis control among stakeholders by considering a number of different studies in developing and developed countries.

The researchers advise that multilevel assessments (MLA) should be carried out to identify stakeholders and understand their viewpoints.  Much research focuses on understanding one or two issues within a programme.  In contrast a MLA uses a range of methods to identify the perspectives of all stakeholders.  It also involves an analysis of the socioeconomic, cultural and political environment within which the intervention is to be delivered.  Such an assessment can provide valuable insight to help turn a health policy into effective practice.

Based on existing research evidence, the authors make the following points:

• Research from South Africa reveals that many women had never heard the word ‘syphilis’, whilst in areas of the United States one in four respondents did not know it could be cured. If potential clients do not see syphilis as a problem or do not know that it is curable, there will not be a demand for treatment services.
• One study showed that up to half of GPs in Karachi, Pakistan, could not describe the correct management of syphilis.  If service providers have little knowledge of the disease or are poorly motivated, they are unlikely to provide a high quality service.
• The perspectives of health policy-makers are explored in only a small number of studies.  This is despite the crucial importance of their role in ensuring political, logistical and financial support for programmes.

The two stages of an MLA for antenatal syphilis control are:

• One: to review all existing data which may be found in published or unpublished reports, service-delivery statistics or hospital records.
• Two: to develop culturally appropriate tools to collect information from different types of stakeholders.

Some of the possible stakeholder groups are women and their communities, health care providers, programme managers and policy-makers. Each group has its own perspective and therefore may require different research tools and strategies to overcome its barriers to effective screening programmes.

Tools which may be useful with many different kinds of stakeholders include:

• community and client focus groups and exit interviews
• direct questioning of service providers and ‘mystery client’ techniques
• use of the Reproductive Tract Infections Programme Guidance Tool (RTI-PGT), developed by the WHO and the Population Council, to assess a programmes’ performance
• political mapping, stakeholder interviews and structured policy analysis at policy level.

It is important to stress that a MLA is not sufficient to ensure that programmes are effective and sustainable. In contrast to some more high-profile diseases, there is a lack of community activism or strong political support for syphilis control. Health care professionals can be resistant to attempts to introduce 'one more health intervention'. Emphasis should be placed on the technical and economic rationale for action, while at the same time syphilis control could be linked to a more politically ‘successful’ issue such as prevention of mother-to-child HIV transmission.  The likely success of such an approach will, however, depend on the local context.

Source(s):
‘Antenatal syphilis control: people, programmes, policies and politics’, Bulletin of the World Health Organisation 82(6), by S. Hawkes et al, 2004 Full document.
'Antenatal syphilis in sub-Saharan Africa: missed opportunities for mortality reduction', Health Policy and Planning 16(1): 29-34, S. Gloyd, S. Chai and M.A. Mercer, 2001
'Integrating reproductive health services in a reforming health sector: the case of Tanzania', Reproductive Health Matters 11(21): 37-48, M. Oliff, P. Mayaud, R. Brugh and A.M. Semakafu, 2003

id21 Research Highlight: 12 October 2004

Further Information:
Sarah Hawkes
London School of Hygiene and Tropical Medicine
Clinical Research Unit
Keppel Street
London WC1E 7HT
UK

Contact the contributor: sarah.hawkes@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Other related links:
'Is antenatal syphilis screening still cost effective in sub-Saharan Africa?''

'Screen test: detecting and treating syphilis in pregnant women in Tanzania'

'Altogether now? HIV prevention by mass treatment of sexually-transmitted infections'

'Antenatal care reborn? Healthcare for pregnant women in developing countries'

See id21's collection of links relevant to maternal and child health.

See id21's collection of links relevant to sexual and reproductive health.