It is believed that since HIV/AIDS receives more resources compared to maternal and child health, integrating it in maternal and child health services will strengthen the maternal and child health platform, which has remained weak over the years due to limited funding.
Research indicates that majority of expectant women in most sub-Saharan African countries attend antenatal clinics. A good proportion of these women deliver in health facilities. Research also indicates that majority of children under five years
receive essential vaccines through the healthcare system in most sub-Saharan African countries. It makes sense therefore that providing HIV/AIDS and family planning (FP) services as part of the antenatal care (ANC), delivery, and newborn and child health services can greatly increase access to these services and save lives.
Even then, we know that HIV/AIDS programmes have been historically set up as parallel programmes within the healthcare system in most countries. In recent times, however, there is increasing focus on the need to integrate HIV/AIDS and FP services into the existing maternal and child health platform to increase access to HIV/AIDS care.
In a recent study funded by the Bill and Melinda Gates Foundation, AFIDEP found that although sub-Saharan African countries have made varied policy responses to calls for integration of sexual and reproductive health (SRH) and HIV/AIDS, they face similar challenges in making service integration a reality. The study, conducted in the Democratic Republic of Congo (DRC), Malawi, Tanzania and Zambia, sought to provide an understanding of the landscape of maternal, newborn and child health (MNCH), FP, and the HIV/AIDS burden, service deficiency and integration efforts in Eastern and Southern Africa. The purpose was to provide the Gates Foundation evidence that can inform the Foundation’s future investments for promoting integration in sub-Saharan Africa.
A major challenge that all study countries face is weak health systems, including vertical structures and planning mechanisms within the government (e.g. within the Ministry of Health and between the Ministry and the National AIDS Commission);
inadequate funding, especially for sexual and reproductive health issues including maternal health; insufficient and inadequately skilled health workers; lack of equipment; weak supply chain systems occasioning frequent commodity stock-outs, and weak
monitoring and evaluation systems to monitor integrated services.
Although there have been calls for integration using the maternal, newborn and child health platform since 2008, many countries including the four study countries, have not made much progress in enabling integration through this platform. At policy level, only Tanzania has developed guidelines for enabling the integration of maternal, newborn and child health and HIV/AIDS services. Malawi is in the process of developing a strategy for integration of sexual and reproductive health and HIV/AIDS services, whereas DRC and Zambia do not have integration policies, strategies or guidelines. DRC and Zambia, however, argue that their broad health sector policies have adopted the primary health care principles, which underscore service integration, and do not therefore see the need for an integration policy.
At service delivery level, there are various integration programmes being implemented in the four countries. The prevention of mother-to-child transmission of HIV/AIDS (PMTCT) programme remains the major integration effort with reasonably high levels of coverage in Malawi, Zambia, and Tanzania, but quite low in DRC. There is, therefore, substantial scope to ensure universal access to PMTCT treatment for the many HIV-positive expectant women or HIV-exposed infants to help reduce mother-to-child transmission of HIV. The four countries could benefit from ongoing advocacy and programme efforts to integrate PMTCT and MNCH, which research has shown could reduce the loss of follow-up of many mothers and infants.
Other integration programmes in the four countries range from integration of FP into HIV testing and counselling, FP into HIV care and treatment, HIV into FP, FP into PMTCT, PMTCT into MNCH, and FP and HIV/AIDS into MNCH. Notably though, most of these programmes are funded by donors, implemented by nongovernmental organisations, and are implemented on pilot basis in a few regions/districts/health facilities. Funding agencies largely fund parallel programmes on different aspects of SRH/MNCH, FP and HIV/AIDS through different implementers. Consequently, there is a myriad of programmes collaborating with the Ministries of Health in these countries to offer different models of integrated services.
The study revealed that there is limited conscious effort in the four countries to expand HIV/AIDS and FP services through the widely used maternal and child health platform. In fact, the maternal and child health programmes remain greatly underfunded in all four countries, a factor that hinders integration. Stakeholders in the four countries were in agreement that the maternal and child health platform provides important opportunities for increasing the uptake of HIV/AIDS and FP services. Even then, there was agreement that the platform needs to be strengthened –increased funding, adequate human resources and strong monitoring and evaluation processes– if efforts to integrate HIV/AIDS and FP services within the maternal and child health services are to be effective.
The study identified five main potential areas where funding agencies, including the Gates Foundation, could prioritise in order to strengthen countries’ efforts for enabling service integration as summarised here:
Funding agencies should fund integrated programmes as opposed to funding MNCH, FP and HIV/AIDS programmes separately.
The shift in PEPFAR funding in 2009 to focus on integration of maternal and child health and FP services in its HIV/AIDS programme has been noted as having greatly contributed to enabling the provision of integrated services in many sub-Saharan African countries. This demonstrates that if integration efforts start within funding agencies, then these will more likely translate to service integration in health facilities in the beneficiary countries.
Strengthen governments’ capacity in policy development, planning, operationalisation and coordination of partner efforts.
This study and others highlight the challenge of government’s weak capacity to enable effective policymaking, planning, operationalisation of policies and coordination of partner efforts. It is important to note that this is a challenge whose solution may be complex, and therefore critical for funding agencies to think through and consider piloting this kind of support in one country in order to draw lessons for sustained improvement, but also for informing similar efforts in other countries.
Strengthen critical functions of the health system.
The weak health system functions in most sub-Saharan African countries remain major hindrances to effective integration efforts. The critical functions that need urgent investments to support integration efforts include the human resources, commodity supply chain, and the monitoring and evaluation. There are various ongoing efforts by governments and partners to address these challenges, but there is need for these efforts to be reinforced or scaled-up.
Strengthen community level provision of integrated MCH, FP and HIV/AIDS information and services.
Provision of community level information and services remains a critical life-saving interventions in most African countries given the huge challenge with accessing facility-based services in rural and hard-to-reach populations, which form the bulk of populations in African countries. Given the demonstrated effectiveness of community level service provision as seen in Ethiopia, we believe that investments in interventions that enable the provision of integrated information and services at community level will enhance the reach of integrated services to the sub-populations most in need.
Increase funding for the maternal and child health platform.
It is widely acknowledged that the maternal and child health platform presents often missed opportunities for strengthening the provision of integrated services, including integration of FP and HIV into ANC, integration of FP and HIV into delivery and post-natal care, and integration of FP and HIV into child immunisation care. Despite these opportunities, there is limited funding for the maternal and child health platform, presenting an opportunity for funding agencies to prioritise funding this platform, which will in turn enhance integration opportunities.
“…there is limited conscious effort in the four countries to expand HIV/AIDS and FP services through the widely used maternal and child health platform…“