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Integrating STI services proves problematic.

Recent efforts to integrate the management of sexually transmitted infections (STIs) into existing maternal and child health-family planning (MCH-FP) services in four African countries illustrate how qualitative data can be used with quantitative data to detect and explain difficulties in implementing new reproductive health policies.

Integrating STI prevention, diagnosis, and treatment into existing MCH-FP services, a fundamental component of the agenda discussed at the 1994 International Conference on Population and Development in Cairo, is considered to be a key approach to improving reproductive health services in many countries. Services to be integrated include STI risk assessment; pelvic examinations; syphilis screening; counseling, diagnosis, and treatment for HIV and other STIs; condom promotion; and distribution of information, education, and communication materials. MCH-FP facilities in Ghana, Kenya, South Africa, and Zambia have attempted to integrate these services, but qualitative research shows the process to be problematic to some extent in all four countries.

A recently published review from the University of Leeds and the London School of Hygiene and Tropical Medicine in England found integration of STI and HIV management into family planning services to be generally poor. Furthermore, it found that such attempts at integration may misdirect scarce public health resources since many people at risk for STIs do not use family planning services. On the other hand, MCH services emerged as an alternative--and potentially more effective--route for integration since most women in these countries obtain antenatal care. (1)

In the review, quantitative data from the Ministry of Health in South Africa and from national situation-analysis surveys in Ghana, Kenya, and Zambia were used to determine the extent of integration and the prospects for expanding these services. Policies designed to integrate STI management with MCHFP services in the four countries were also compared qualitatively through case studies. Semi-structured interviews were conducted with governmental and nongovernmental officials; a structured survey of 80 health facilities throughout the four countries was performed; and interviews and focus group discussions were held with health care providers at those facilities.

Analyses of data from the four countries revealed the following:

* The decentralized decision-making and management necessary for integration has been difficult to achieve owing--in large part--to a tradition of maintaining separate policies, management, funding, training, and procurement and delivery systems for each area of reproductive health: family planning, MCH, and STI and HIV prevention.

* In Ghana, Kenya, and Zambia, multiple reproductive health policies and guidelines have been promoted, resulting in many strategic plans and technical guidelines that confuse providers who are attempting to prioritize services when resources are scarce.

* Although all four countries have developed STI management guidelines that have been disseminated among regional or provincial staff, qualitative data showed that supervision and follow-up assessment of guideline use has not occurred. Thus, the degree to which policies are being implemented has been difficult to determine.

* Financial, technical, and human resources to carry out policies and strategies may be lacking in the study areas, and bureaucratic hierarchies discourage communication among regional and district managers and national policy-makers. As a result, providers at clinics may be asked to implement unrealistic, inappropriate, or insufficiently supported policies.

* Equipment for basic pelvic examinations is available in all study areas, but qualitative data showed that the availability of other key resources is uneven across the four countries. These resources include counseling; training; information, education, and communication materials; and drugs for treating STIs.

Qualitative work also revealed potential problems with training of personnel and the freedom to put training into practice. For example, in all four countries, doctors and others in the medical community often opposed, and thus hindered, the practice of nurses prescribing STI drugs, even when existing law allowed nurses to do so.

Overall, quantitative data indicated a generally low availability of STI services at MCH-FP facilities in Ghana, Kenya, and Zambia: Only 28 percent to 46 percent of the facilities surveyed offered any form of STI diagnosis or treatment, even in areas with resources to do so. (In South Africa, where reproductive health services are less compartmentalized, more than 75 percent of the facilities offered some form of STI management.) Quantitative data showing that mention of condoms to new family planning clients in Ghana, Kenya, and Zambia was uneven--ranging from a high of 72 percent to a low of 12 percent were reinforced by the authors' qualitative interview data showing minimal promotion of condoms for dual protection.

A more recent review article from the New York-based Population Council on the integration of STI prevention and management into existing family planning and antenatal care facilities in sub-Saharan Africa confirms the findings of the multi-country review. The article, coauthored by Dr. Ndugga Maggwa, who is currently the regional director for FHI's family planning and reproductive health program in east and southern Africa, suggests that more research-based evidence of the feasibility, cost-effectiveness, and impact of integration is needed. (2)


(1.) Mayhew SH, Lush L, Cleland J, et al. Implementing the integration of component services for reproductive health. Stud Faro Plann 2000;31(2):151-62.

(2.) Askew I, Naggwa NB. Integration of STI prevention and management with family planning and antenatal care in sub-Saharan Africa--what more do we need to know? Int Fam Plann Perspect 2002;28(2):77-86.
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Title Annotation:sexually transmitted infections
Author:Wright, Kerry L.
Geographic Code:6GHAN
Date:Dec 22, 2002
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