There was need to get a general understanding of the concept of integration, so I asked the Professor Craig Cohen, Department of Obstetrics, Gynaecology and Reproductive Sciences, University of California San Francisco to state, in very simple terms, what integration of SRH and HIV services means for countries.
His answer was simple and to the point: “Improved services for men and women all over the world and generally with improved family planning services.”
At the 2012 Integration for Impact conference, held in Nairobi last week (12-14 September), there were indeed many mentions and discussions of various forms of integration, attempted in quite varied contexts across Africa and as far as Asia. From almost 130 different forms of presentations discussed there was quite a variety.
It is important to note that, the view of some conference participants was that the integration of health services is really nothing so much out of the box. It already exists. To achieve the desired health results what’s important will be the deliberate effort to improve crippled health systems. For instance, even many years before this Nairobi conference, there have been forms of integration such as the Integrated Management of Childhood illnesses (IMCI) programme.
A seasoned BBC health journalist Tom Jappani agrees with some of these sentiments: “For an urban dweller, when you go to a hospital or health facility, that is what you expect, a range of facilities in one place. After registration, there is the laboratory; they take your blood sample. If there is a problem with your teeth, you see a dentist, you are briefed by the doctor in the same place and then you head to the pharmacist to get your medicine. This has been there in the urban facilities. The trouble is that such a service is not there in the rural areas. In that case, African governments should give the people in the rural areas the same health services that they are giving the urban dwellers.”
Just after the conference, this week in Uganda, there was a report of a pregnant woman in Mukono, with obstructed labour who was kicked out of a health centre IV for failure to pay medical bills worth Uganda shillings 250,000 (100 USD). The medical personal and the facilities were there. Such cases underscore the significant barriers, including the existing infrastructure shortages and low motivation of staff. These may have to be addressed within the vertical facilities if greater integration especially SRH and HIV can be achieved.
There is also the worry of almost letting those who test negative for HIV ‘loose’ without caution after testing. I channelled this worry to Dr. Lawrence Oteba, SRH and HIV linkage advisor at IPPF African region office: “You are doing well as required to enrol those found HIV positive on ARVs but what do you do for those that are tested HIV negative?”
His answer gives a glimmer of hope: “We are taking them seriously. Whereas the PLHIV benefit as earlier as possible from the care treatment and support (CTS) available, because we are also looking at early treatment and adherence to ARVs as prevention [studies indicate that with a very low viral load, there is low risk of transmission].
“For the HIV negative, we want to them remain negative. This is reinforced by more information, healthy sexual and reproductive [practices] and continuous counselling so that they have services whenever they need them.”
Hopefully, this will prevent those not living with HIV brandishing their ‘status certificates’ everywhere, long after they had been tested, telling people in bars and villages they are not infected with HIV.
Another issue is the familiar scenario of the sustainability. What are the great research-based interventions going to do after the projects have run out of time? There have been vast amounts of funds disbursed in such randomised trials. In most cases, the trials have demonstrated that certain models are better for SRH and HIV integration. The achievements realised from these projects are always clearly visible during the project durations. Left with a pile of evidence to replicate, African governments normally appear to be ‘orphaned’ when experts from Europe and other Western governments pack up. Won’t the facilities collapse after the project ends? Will staff remain motivated long after the intervention studies have ceased?
Some of these questions need to be answered if Professor Craig Cohen’s concept of ‘integration for all’, mentioned above, is to remain relevant. We may not want all research on health integration and other areas of biomedical benefit, such as SRH and HIV integration, living within the health implementation challenges of Africa that never seem to end.