Integrating Health Services is the Means, Not the End

Rudi Thetard. {Photo credit: MSH.}Photo credit: MSH.

Pervasive, chronic poverty has devastated every sector of Malawi for decades—contributing to a faltering economy and applying enormous pressure on an overextended and under resourced government.  A fragile health care infrastructure is aggravated by the poverty problem and has increased the prevalence of HIV & AIDS, tuberculosis, malaria, malnutrition, and other epidemics. Malawi has some of the worst health indicators in the world.

Since 2003, MSH programs in Malawi have sought to strengthen health systems, increase disease prevention education, reduce both maternal and childhood mortality rates through reproductive health and family planning initiatives, and integrate health services. Health education and increased access to fundamental health care in communities remain the focus of MSH's work in Malawi. MSH and its partners are striving to facilitate efficient, decentralized management of resources and delivery of fundamental health care services to increase the health of the people of Malawi.

MSH spoke with Rudi Thetard, Chief of Party of the US Agency for International Development (USAID)- funded Basic Support for Institutionalizing Child Survival (BASICS) project, about how to integrate health services and the successes and challenges he has seen in Malawi.

What does it mean to integrate health services?
With my clinical background, when I see a patient, I view the person as a whole entity without fragmenting the person into separate body systems. Clinicians are sometimes surprised by all the talk about integration when clinical care is so naturally integrated at the point of service.

While the global health community talks about integrating health services, we often find that services are to a great extent already integrated at the level of service provision, either through a one-stop -shop approach (where a number of services are provided at the same geographic site) or through a multi-purpose health worker who may see a child at one moment and, later an adult with a chronic disease.

In some cases, it is convenient to have specialists (such as in busy hospital or clinic setting (where specialized knowledge and care is required) while others, such as in rural areas, the multi-purpose worker is the best service provision option. It is better not to have fixed ideas whether to integrate or not, but develop a service provision approach based on the context and setting.

The challenge comes further up the system, when services are being managed and organized. At the district level, it is important to have someone who follows up on issues of malaria (a malaria coordinator) where a level of specialized knowledge is needed to effectively implement a program.  This person should not attend a malaria meeting one day, and the next day attend a tuberculosis (TB) meeting. It does not work well that way.

It is not necessary to integrate the programming at this level or even at more lofty levels of the health system structure. It is necessary to search for synergies between programs to ensure effective implementation and reduce duplicative efforts.

How does vertical funding impact delivering integrated services?
There are interesting examples in Malawi where it is possible to leverage vertical program funding in support of integrated programs. MSH was able to help the Ministry of Health pool Presidential Malaria Initiative (PMI) funding and Child Survival funding to provide community case management services.  An agreement was reached that PMI case management funding would not be targeted at fever specifically, but also covers fever, diarrhea, and pneumonia. Service providers are trained and equipped with supplies to provide an integrated package of services.

BASICS and the Community-based Family Planning and HIV & AIDS Services (CFPHS) program in Malawi have been working together to build the capacity of community health workers to provide Depo-Provera (a form of family planning medication) and community case management services. Now, a single provider provides both these services. It is quite an important development.

Why is transitioning to an integrated approach important in developing countries?
Integration should be seen as a strategy, not the goal. It is not so much that we must integrate, but there are certain points where it is better to integrate.

We cannot integrate everything. But, we can examine the services that need to be provided and at least see what services make sense to provide in an integrated fashion.

There are limits to integration as well. For example, does the problem occur regularly enough to ensure that the provider retains the necessary skill level?

How are services integrated?
The most practical way is to have an idea of what you want to integrate and be clear about the end goal.

Preventing Mother-to-Child Transmission (PMTCT) of HIV services has required that we integrate certain activities into the routine prenatal package of care. This includes appropriate nutritional advice, performing a HIV test, and, initiating antiretrovirals (ART, AIDS medicines) for all HIV positive pregnant women. These services may all be provided from a single service provision site, but the nurse may add the nutritional advice to the routine consultation process,  or we may employ a counselor to conduct the testing (it is inefficient to have the nurse conduct testing with a high workload) while a clinician or the nurse may initiate the ART.

A well thought out assessment and approach towards exploring the activities that need to be implemented are important when planning effective integration of services. Similarly, knowing what we need to achieve is very important.

What impact has integrating services had in Malawi?
The key thing is that we have expanded access to health services, specifically family planning and community case management services by training community health workers. Not only are we expanding the amount of service sites, but child mortality and morbidity is decreasing as seen through the Demographic and Health Survey results.

In the next few months, the Ministry of Health is going to introduce new HIV treatment guidelines. This will represent another opportunity to explore the integration of services.  Malawi is taking the route of Option B+. The heart of Option B+ is that if a pregnant woman is found to be HIV positive, she immediately goes onto antiretrovirals life-long.

The implication is that all sites providing prenatal care will be able to provide ART and there will be a huge expansion of ART provision throughout Malawi. There is the potential to greatly reduce maternal mortality and transmission to child during the pregnancy and after.  This does however require extensive planning and preparation – another crucial issue in terms of successfully integrating services.

Are TB services being integrated with HIV services in Malawi?
That is slowly happening. Providers are generally trying to link it to make sure if a client comes in for an antiretroviral consultation, and they have TB, they will also get their TB medication. It is a one-stop shop approach through the use of different providers.

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