Notes on Integrated Approaches to Improving Maternal, Newborn and Child Health

Women's Policy, Inc., PATH, and Congressional Women’s Caucus Members

September 15, 2010

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MalariaTB

MalariaTB

Our vision for a more integrated health delivery system in maternal and child health, family planning, nutrition and HIV

Maternal health

Policy

Service delivery

Program Management

Child health

Policy

Service delivery

Program Management

Family planning

Policy

Service delivery

Program Management

Nutrition

Policy

Service delivery

Program Management

How can we go from this…

HIV

Policy

Service delivery

Program Management

Policy

Service delivery

Program Management

… to something more like this?

Nutrition Maternal healthChild health Family planning HIV

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The Global Health Initiative aims to integrate the delivery of health services to increase efficiencies and effectiveness

Areas where better integration is possible• 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

willingness to seek care• Strengthen program management and

sustainability• Strengthen the health system• Better outcomes for women and children

“Strategic” integration recognizes there are limits to application of this approach

• Integrate to increase efficiency, convenience, and/or value

• Avoid overloading schedules or space• Don’t overwhelm staff or clients with range of

offerings

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Service delivery integration will gives patients access to a broader range of services and with greater convenience

• Identify areas where integrating interventions is more efficient and effective

• Increases likelihood that women, children and men will receive appropriate services

• Packages of care tailored to local conditions and needs

– Include antenatal and maternity, child health, nutrition, family planning

– Link to HIV/AIDS, STIs, tuberculosis, malaria, immunizations

Patients see a difference at point of service

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Integration of family planning/reproductive health and HIV shows promise

Significantly greater access to FP• Integrating FP and HIV services can reduce the unmet need

for FP for more than 200 million women

Treat STDs and reduce the spread of HIV • Integrated reproductive health and HIV services can address

overlapping health needs since the majority of HIV cases are transmitted sexually and those with active STIs are at greater risk 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 HIV testing, counseling and treatment

Data-driven approach• USAID supporting review of FP-MNCH and HIV-MNCH

integration

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Some examples of integrated service delivery in different settings relevant 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 TB screening 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 preventive malaria 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 and childhood health services

• Assess nutrition and health status of children accompanying women who come for reproductive health and family planning services

• With immunization programs include micronutrient supplements, bednet distribution, and family planning, nutrition, and HIV prevention education.

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GHI also supports integration at the program management and policy levels – which in turn supports integrated service delivery and promotes program efficiency

Examples of where integration can help increase access and deliver better care

Policy• Support country-level policy efforts such as

producing national guidelines on integrated services, coordinating donors and funding streams for different programs, and making organizational changes to promote integrated programs

Training• Integrate training programs to cross-

train health care workers and public health staff in different service delivery procedures and program areas

Program monitoring & evaluation • Integrate monitoring and reporting

systems to reduce reporting burden and free staff for clinical work, consider together various program outputs

Operations and logistics• Integrate approach to strengthening

health systems, e.g. supply chain management to avoid stock-outs

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An example of doing this at scale – Ethiopia’s Integrated Family Health Program

In Ethiopia, PMTCT was added to an existing and strong FP/MCH platform

ResultsIn the past 5

years, the contraceptive

prevalence rate has increased

from 13.6% to 29.3%

ResultsIn the past 5

years, the contraceptive

prevalence rate has increased

from 13.6% to 29.3%

Program size and structure• FP/MNCH service delivery

program in 286 districts of the four largest regions of the country reaching 80% of the population

• Involves 10,000 community health workers and 223 health facilities that offer FP/HIV integration

• Supervision and mentoring of health workers

• FP services strategically target most at-risk populations, young women and married couples

• The reporting is through the FP program. HIV reporting goes through the PEPFAR channel

Program services• Primary prevention of HIV

– FP counseling includes STI and HIV prevention

– Voluntary counseling and testing for HIV is integrated with FP

• Prevention of unwanted pregnancy– Integrated services at the health

facility level and community outreach

• Treatment given to pregnant women– Antenatal and post partum care

include family planning counseling

• Treatment for women and their families– FP referrals at treatment sites– Community outreach by health

extension workers promoting and offering family planning

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We are promoting a culture of evidence and quality in these programs

Learning agenda priorities

Challenge

• Data on costs and effectiveness of integrated programs remains limited

• Experience also limited so potential for unintended negative consequences of integration not well understood

• Accrue an evidence base on

integrated service provision

• Carefully evaluate different

approaches

• Possible metrics include– Impact of integration on

utilization of specific services– Satisfaction of staff and users– Cost– Adherence to service delivery

and data collection protocols