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Jamaica: system-wide integration of services.

Most integrated delivery of family planning and HIV services is limited to pilot projects in one or a few health facilities. Little is known about how to integrate these services throughout a health care system.

But a study in Jamaica seeks to identify changes needed to make family planning and HIV service integration a reality system-wide. Conducted by the Jamaican Ministry of Health (MOH) and the Washington, DC-based POLICY Project of the Futures Group among 100 health care providers, program managers, policy-makers, and potential clients, the study will determine the feasibility and potential cost of integrating family planning and HIV services in the rural parish (district) of Portland and the urban area of St. Ann's Bay.

"We are asking, 'What policies, regulations, and guidelines need to change to actually institutionalize integration?'" explains Dr. Karen Hardee, research director for the POLICY Project.

The MOH has identified service integration as a priority to better meet the reproductive health needs of Jamaicans. Offering HIV prevention counseling and diagnosis and treatment of curable sexually transmitted infections (STIs) at family planning and maternal and child health facilities and through outreach is considered a good way to improve women's access to these services. It would also offer opportunities to provide comprehensive reproductive health services for youth and to attract male clients who could receive counseling about family planning and HIV/STI risk reduction, as well as STI treatment. (1)

Reaching Jamaican women and youth is particularly important because they are at higher risk of infection with HIV and other STIs than are Jamaican men. HIV prevalence among Jamaican adults is relatively low, at 1.2 percent. (2) But rising levels of HIV infection among women have narrowed the ratio of male-to-female AIDS cases: In the 1980s, that ratio was 6 to 1; in 2001, it was 1.6 to 1. Women now account for 40 percent of all AIDS cases reported since the epidemic began, and girls ages 10 to 19 years are two and a half times more likely than teenage boys to be infected with HIV. (3) In one study in the capital, Kingston, 27 percent of female family planning clients with no STI symptoms were found to have an STI. (4) And half of reported cases of gonorrhea occur among Jamaican youth ages 15 to 19 years. (5)

The feasibility study began with workshops that brought together national, regional, and parish-level health officials; nongovernmental organization staff; and public and private health care providers to develop a plan for service integration in Portland and St. Ann's Bay. The plan outlines 20 possible strategies for combining family planning and HIV services and improving access to integrated services.

The proposed strategies address training, screening, access, referral, outreach, patient education, management information systems, and treatment. They range from training all providers in a more integrated approach to counseling and service delivery, to hiring additional staff at specific facilities.

Local research organizations carried out four feasibility studies of these strategies. They conducted interviews and focus group discussions with providers to assess their willingness and ability to provide integrated services. They gauged clients' reactions and perceptions of stigma through focus group discussions. Finally, they analyzed operational constraints to service integration and identified the cost per STI treated for each strategy in the proposed plan.

Data collection ended in April 2004. Once the data have been analyzed, the MOH and the POLICY Project will use the findings to plan how to remove operational barriers to family planning and HIV integration in Portland and St. Ann's Bay. The experience with integrated services in these parishes will, in turn, guide decisions about integrating services throughout the country.


(1) Jamaica Ministry of Health North East Regional Health Authority and the POLICY Project. Determining the feasibility and potential scope of integration of reproductive health (FP/MCH/STI/HIV) services, using Portland and St. Ann's Bay as pilot sites. Unpublished paper. The Futures Group, 2002.

(2) Joint United Nations Programme on HIV/AIDS (UNAIDS). Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections, 2002 update: Jamaica. UNAIDS, 2003. Available: Jamaica_EN.pdf.

(3) Jamaica National AIDS Committee. Jamaica AIDS Report January-June 2003. Available: didyouknow.htm.

(4) Behets F, Ward E, Fox L, et al. Sexually transmitted diseases are common in women attending Jamaican family planning clinics and appropriate detection tools are lacking. Sex Transm Infect 1998;74(Suppl 1):123-27.

(5) McLain B, Hardee K, Levy D. Reproductive Health in Jamaica. Volume II. Background Data for Analysis of Current Reproductive Health Status, Gaps, Needs and Opportunities. Washington, DC: The Futures Group, 1999.
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Title Annotation:Case Studies
Author:Shears, Kathleen Henry
Geographic Code:5JAMA
Date:Mar 22, 2004
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