Politics and science played a role in promoting integrated reproductive health to the fore of the international agenda. The 1994 International Conference on Population and Development advocated a radical shift towards holistic care for women in response to strong political pressure from women's groups. The following year, the Mwanza trial results provided dramatic evidence that offering STD treatment within primary health care, instead of separately, could help prevent the spread of AIDS. Internationally, the promotion of 'integrated reproductive health' followed, with donors eager to support such policies in low income countries. Little is known, however, about whether or not this approach can be translated into practice, especially where STD/HIV services have traditionally been provided separately.

Examining practicalities in Ghana, Kenya and Zambia, researchers asked how donors and governments interact. Findings suggest there are three major challenges to a successfully-integrated reproductive health service.

• Health service delivery is split down international agenda lines for family planning, maternal health care, STDs and HIV. Financial and administrative arrangements are often separate and supported separately by government and donors. USAID and UNFPA, for example, support family planning in Ghana, while UNICEF backs Safe Motherhood in Ghana and Zambia.
• Despite their international rhetoric, donor insistence on programme accountability and rapid attainment of measurable results further encourages separate management. Even at local levels donors shy away from partnership with government, preferring to separate priority activities from the mainstream. For example, in Ghana and Zambia, USAID and UNFPA support delivery of contraceptives through their own supply systems. Likewise, the World Bank in Kenya created a separate tier of HIV/STD officers in district administrations to ensure programme success.
• A very real fear exists that political and economic instability undermine the accountability sought by donors. Donors thus opt for small, self-contained projects that governments need hold no stake in. A UNICEF project saw a drop in syphilis among pregnant women in Zambia but because procurement of drugs and test-kits was undertaken by UNICEF, activities could not be sustained or scaled up once its funding ceased.