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April 1997 Insights Issue #22Integrating services from rhetoric to actionThe current emphasis on a broad approach to
reproductive health has led to calls for integration of family planning
and maternal and child health programmes (FP/MCH) with HIV and STI
control programmes, particularly for women of childbearing age. The
appeal of integration is that both HIV/STI and FP/MCH activities share a
common interest in encouraging a more rational, informed and prudent
approach to sexual intercourse and its possible consequences.
Surprisingly little is known about how to achieve this shift.
A complete package of reproductive health services would include
family planning advice and contraception, infertility services, general
gynaecology, urology, ante- and post-natal services and diagnosis and
treatment of STIs. The main advantages of providing these services in
one place are in sharing fixed costs and extending HIV/ STI services to
women whose needs are currently not met. However, there are also
disadvantages to integration. Services may become overstretched, both
financially and in terms of staff time and skill. Integrated services
may not be the most effective way of reducing prevalence and
transmission of HIV/STIs, especially since they may miss other important
groups such as men or the young and unmarried. Treatment and diagnosis
of STIs are also more complicated than many of the services currently
provided, both clinically and in terms of laboratory and diagnostic
equipment required.
Health outlets in many countries currently describe their service
delivery as integrated, but patterns of integration vary considerably.
No single blueprint can exist. For example, there may be a high level of
integration in an outlet while, at a policy level, FP/MCH and HIV/STIs
have separate, vertical management systems. Indeed, FP and MCH
themselves may not be integrated. District hospitals may have both
FP/MCH and HIV/STI treatment and prevention in one site but, in rural
health centres, comprehensive services may not be feasible.
Alternatively, HIV/STI and FP/MCH clinics might be run at the same
outlet on different days or at different times, with a range of staff
catering to the needs of varied clientele. The appropriateness of
different types of HIV/STI service also depends on the prevalence of
disease: high prevalence situations suggest mass treatment approaches;
low prevalence situations require careful targeting of high risk groups.
Policy decisions on these services need to take account of the
attitudes of key actors and of the costs of different models of care,
though few studies have examined these and financial data are rarely
available. At the provider level, information is needed on the nature,
quality and accessibility of services currently provided and on how
service delivery personnel might be trained to perform additional tasks.
Different levels of STI/HIV service integration will be feasible for
different types of FP/MCH service delivery. Family planning services are
increasingly being provided by non- medical personnel so ante-natal
care, for example, may be a better point at which to integrate STI/HIV
services. At the client level, it is not always clear how current and
potential clients of FP/MCH services might react to an expanded
reproductive health service and what its impact on users might be.
These questions are being addressed in a new study in four countries
in Africa (Ghana, Kenya, Zambia and Zimbabwe) chosen to be regionally
representative with some variation in approach to FP/MCH and HIV/STI
service delivery. Policy processes and programme management issues which
have arisen and a demographic and epidemiological picture of the kinds
of services needed will be described and attitudes amongst providers and
their clients towards integration will be investigated in each case,
with a view to drawing out common themes and policy lessons.
Louisiana Lush, |
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