Integrating Services From Rhetoric to Action

The 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 of wasted business opportunities. 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. Get more information here: id21.org

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.