Notes on Integrated Approachesto Improving Maternal, Newbornand Child Health
Women's Policy, Inc., PATH, and Congressional Women’sCaucus Members
September 15, 2010
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Malaria
TB
Malaria
TB
Our vision for a more integrated health delivery system in maternaland child health, family planning, nutrition and HIV
Maternal health
Policy
Service delivery
ProgramManagement
Child health
Policy
Service delivery
ProgramManagement
Family planning
Policy
Service delivery
ProgramManagement
Nutrition
Policy
Service delivery
ProgramManagement
How can we go from this…
HIV
Policy
Service delivery
ProgramManagement
Policy
Service delivery
Program Management
… to something morelike this?
Nutrition
Maternal health
Child health
Family planning
HIV
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The Global Health Initiative aims to integrate the delivery of healthservices to increase efficiencies and effectiveness
Areas where better integration ispossible
•Maternal health
•Child health
•Family planning
•Nutrition
•HIV
Points at which integration are important
•Service delivery
•Program management
•Policy
Why do this?
•More efficient use of scarce resources
•Expanded service delivery and access
•Better experience means more willingnessto seek care
•Strengthen program management andsustainability
•Strengthen the health system
•Better outcomes for women and children
“Strategic” integration recognizes there are limitsto application of this approach
•Integrate to increase efficiency, convenience, and/orvalue
•Avoid overloading schedules or space
•Don’t overwhelm staff or clients with range ofofferings
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Service delivery integration will gives patients access to a broaderrange of services and with greater convenience
•Identify areas where integrating interventions is moreefficient and effective
•Increases likelihood that women, children and menwill receive appropriate services
•Packages of care tailored to local conditions andneeds
–Include antenatal and maternity, child health,nutrition, family planning
–Link to HIV/AIDS, STIs, tuberculosis, malaria,immunizations
Patients see a difference atpoint of service
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Integration of family planning/reproductive health and HIV showspromise
Significantly greater access to FP
•Integrating FP and HIV services can reduce the unmet needfor FP for more than 200 million women
Treat STDs and reduce the spread of HIV
•Integrated reproductive health and HIV services can addressoverlapping health needs since the majority of HIV cases aretransmitted sexually and those with active STIs are at greaterrisk for contracting HIV
More people will come to clinic
•Integrated services can reduce stigma and put clients at ease
•People therefore more likely to seek and continue HIVtesting, counseling and treatment
Data-driven approach
•USAID supporting review of FP-MNCH and HIV-MNCHintegration
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Some examples of integrated service delivery in different settingsrelevant to MCH/FP/Nutrition/HIV program areas
•Use community-based MCH and nutrition services to follow up HIV+women and HIV-exposed and infected infants and children, perform TBscreening and contact tracing
•Combine messages in behavior change communication
•Bundle commercial and social marketing for family planning, ORT,micronutrient supplements, safe birth kits, bednets, soap and point-of-use water treatment, and other family health products
•Provide voluntary HIV testing and counseling, intermittent preventivemalaria treatment, bednet distribution, TB screening, prevention,treatment, and PMTCT with antenatal and maternity services
•Identify newborn or maternal complications and provide nutrition,breastfeeding, and family planning advice through post-partum care andchildhood health services
•Assess nutrition and health status of children accompanying womenwho come for reproductive health and family planning services
•With immunization programs include micronutrient supplements, bednetdistribution, and family planning, nutrition, and HIV prevention education.
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GHI also supports integration at the program management and policylevels – which in turn supports integrated service delivery and promotesprogram efficiency
Examples of where integration can help increase access and deliver better care
Policy
•Support country-level policy efforts such asproducing national guidelines on integratedservices, coordinating donors and funding streamsfor different programs, and making organizationalchanges to promote integrated programs
Training
•Integrate training programs to cross-train health care workers and publichealth staff in different service deliveryprocedures and program areas
Program monitoring & evaluation
•Integrate monitoring and reportingsystems to reduce reporting burden andfree staff for clinical work, considertogether various program outputs
Operations and logistics
•Integrate approach to strengtheninghealth systems, e.g. supply chainmanagement to avoid stock-outs
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An example of doing this at scale – Ethiopia’s Integrated FamilyHealth Program
In Ethiopia, PMTCT was added to an existing and strong FP/MCH platform
Results
In the past 5years, thecontraceptiveprevalencerate hasincreasedfrom 13.6% to29.3%
Results
In the past 5years, thecontraceptiveprevalencerate hasincreasedfrom 13.6% to29.3%
Program size and structure
•FP/MNCH service deliveryprogram in 286 districts of the fourlargest regions of the countryreaching 80% of the population
•Involves 10,000 community healthworkers and 223 health facilitiesthat offer FP/HIV integration
•Supervision and mentoring ofhealth workers
•FP services strategically targetmost at-risk populations, youngwomen and married couples
•The reporting is through the FPprogram. HIV reporting goesthrough the PEPFAR channel
Program services
•Primary prevention of HIV
–FP counseling includes STI and HIVprevention
–Voluntary counseling and testing forHIV is integrated with FP
•Prevention of unwanted pregnancy
–Integrated services at the health facilitylevel and community outreach
•Treatment given to pregnant women
–Antenatal and post partum careinclude family planning counseling
•Treatment for women and their families
–FP referrals at treatment sites
–Community outreach by healthextension workers promoting andoffering family planning
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We are promoting a culture of evidence and quality in theseprograms
Learning agenda priorities
Challenge
•Data on costs andeffectiveness of integratedprograms remains limited
•Experience also limited sopotential for unintendednegative consequences ofintegration not wellunderstood
•Accrue an evidence base onintegrated service provision
•Carefully evaluate differentapproaches
•Possible metrics include
–Impact of integration onutilization of specific services
–Satisfaction of staff and users
–Cost
–Adherence to service deliveryand data collection protocols