Alice arrives at a health center in Western Province, Kenya, with her nine-month-old baby girl, who has a recurrent fever. Alice suspects malaria, which is endemic in the area. Two hours later, she leaves with malaria medication and a free insecticide-treated bed net. To the casual observer, Alice got what she came for and had her health needs met. She even received a bed net she wasn’t expecting.
But consider what Alice didn’t receive. Had her daughter been weighed, the nurse would have noticed that her growth was faltering because Alice is not yet supplementing her diet with nutritious weaning foods. Her daughter also missed the measles immunization she was due for. Alice was not offered an HIV test, which would have revealed that she is HIV-positive. Finally, no one asked Alice, who has six children and does not want to get pregnant again, if she is using a family planning method or would like information about contraceptives available at the health center. In short, Alice’s immediate need was met, but multiple underlying health needs went undetected by the health center staff.
Alice’s story is unremarkable. Similar scenes play out every day in health care settings around the world. In sub-Saharan Africa, where the burden of HIV, unintended pregnancies, and infant mortality is highest, missed opportunities to meet health care needs, such as those of Alice and her baby, can be deadly.
Fortunately, programs in Kenya and Ethiopia are leading the way in integrating family planning, HIV, and maternal/neonatal and child health (FP/HIV/MNCH) services. In Kenya, the government has made integration of FP and HIV a national policy. USAID/Kenya’s AIDS, Population and Health Integrated Assistance II (APHIA II) project promotes integrated service delivery throughout the country in public, private, and faith-based facilities. Visiting the APHIA II project in Western Province (implemented by PATH), I noted that the Ministry of Health trains nurses and health officers to deliver both FP and HIV services. The project has supported FP/HIV/MNCH integration at 276 health centers and hospitals in Western Province. USAID/Kenya’s new APHIA Plus Project will expand integrated services in 2011.
Ethiopia’s Ministry of Health also supports integration and strives to offer an HIV test to all clients coming to public sector facilities. Clients are also assessed for family planning needs and offered counseling and FP methods. The government’s Health Extension Program, supported by USAID/Ethiopia, provides FP counseling and contraceptives in the home, HIV and child health counseling, and referral for services. These public sector efforts are complemented by such programs as FHI’s Home and Community-Based Care (HCBC) program (PDF), which strengthens integrated FP and HIV services offered in the community. The HCBC program is working with local iddirs—traditional neighborhood-based burial societies—that now provide mutual aid services to households affected by poverty and illness, including HIV. The iddirs recruit and manage community health volunteers, who provide home-based care and support to those living with HIV and counsel clients about FP and child health.
I observed many different models of FP/HIV/MNCH integration in Kenya and Ethiopia, including intra- and inter-facility referrals and strong linkages between home and community-based programs and health facilities. The type of integration model used is not as important as the fact that health workers in both countries now view clients more holistically and address more than a single health problem in a consultation or home visit.
The integrated programs I visited in Kenya and Ethiopia all report challenges, such as training health care workers in multiple disciplines and struggling to meet the complex needs of clients in crowded facilities, where it is difficult to focus on more than one health issue at a time. But providers are addressing these challenges through training and task shifting, the use of job aids and reporting systems that capture integrated services, and ensuring that contraceptives, HIV test kits, and other necessary commodities are available. The next time Alice visits a facility supported by these programs, odds are she will have more than just one child’s fever addressed.
Ed Scholl serves as AIDSTAR-One Project Director. AIDSTAR-One is funded by USAID’s Office of HIV/AIDS, and provides rapid technical assistance to USAID and U.S. Government country teams to build effective, well-managed, and sustainable HIV and AIDS programs and promotes new leadership in the global campaign against HIV.