Notes on Integrated Approaches to Improving Maternal, Newborn and Child Health

1. Notes on Integrated Approaches to Improving Maternal, Newborn and Child Health Women's Policy, Inc., PATH, and Congressional Women’s Caucus Members September 15, 2010

2. How can we go from this… Family planning Maternal health HIV Nutrition Child health Service delivery Service delivery Service delivery Service delivery Service delivery Program Management Program Management Program Management Program Management Program Management Policy Policy Policy Policy Policy Policy … to something more like this? Program Management Service delivery Nutrition Child health Maternal health Family planning HIV Our vision for a more integrated health delivery system in maternal and child health, family planning, nutrition and HIV Malaria TB Malaria TB

3. The Global Health Initiative aims to integrate the delivery of health services to increase efficiencies and effectiveness • Areas where better integration is possible • Maternal health • Child health • Family planning • Nutrition • HIV • Points at which integration are important • Service delivery • Program management • Policy • Why do this? • More efficient use of scarce resources • Expanded service delivery and access • Better experience means more willingness to seek care • Strengthen program management and sustainability • Strengthen the health system • Better outcomes for women and children • “Strategic” integration recognizes there are limits to application of this approach • Integrate to increase efficiency, convenience, and/or value • Avoid overloading schedules or space • Don’t overwhelm staff or clients with range of offerings

4. Patients see a difference at point of service Service delivery integration will gives patients access to a broader range of services and with greater convenience • Identify areas where integrating interventions is more efficient and effective • Increases likelihood that women, children and men will receive appropriate services • Packages of care tailored to local conditions and needs • Include antenatal and maternity, child health, nutrition, family planning • Link to HIV/AIDS, STIs, tuberculosis, malaria, immunizations

5. Integration of family planning/reproductive health and HIV shows promise • Significantly greater access to FP • Integrating FP and HIV services can reduce the unmet need for FP for more than 200 million women • Treat STDs and reduce the spread of HIV • Integrated reproductive health and HIV services can address overlapping health needs since the majority of HIV cases are transmitted sexually and those with active STIs are at greater risk for contracting HIV • More people will come to clinic • Integrated services can reduce stigma and put clients at ease • People therefore more likely to seek and continue HIV testing, counseling and treatment • Data-driven approach • USAID supporting review of FP-MNCH and HIV-MNCH integration

6. Some examples of integrated service delivery in different settings relevant to MCH/FP/Nutrition/HIV program areas • Use community-based MCH and nutrition services to follow up HIV+ women and HIV-exposed and infected infants and children, perform TB screening and contact tracing • Combine messages in behavior change communication • Bundle commercial and social marketing for family planning, ORT, micronutrient supplements, safe birth kits, bednets, soap and point-of-use water treatment, and other family health products • Provide voluntary HIV testing and counseling, intermittent preventive malaria treatment, bednet distribution, TB screening, prevention, treatment, and PMTCT with antenatal and maternity services • Identify newborn or maternal complications and provide nutrition, breastfeeding, and family planning advice through post-partum care and childhood health services • Assess nutrition and health status of children accompanying women who come for reproductive health and family planning services • With immunization programs include micronutrient supplements, bednet distribution, and family planning, nutrition, and HIV prevention education.

7. GHI also supports integration at the program management and policy levels – which in turn supports integrated service delivery and promotes program efficiency • Examples of where integration can help increase access and deliver better care • Training • Integrate training programs to cross-train health care workers and public health staff in different service delivery procedures and program areas • Program monitoring & evaluation • Integrate monitoring and reporting systems to reduce reporting burden and free staff for clinical work, consider together various program outputs • Operations and logistics • Integrate approach to strengthening health systems, e.g. supply chain management to avoid stock-outs • Policy • Support country-level policy efforts such as producing national guidelines on integrated services, coordinating donors and funding streams for different programs, and making organizational changes to promote integrated programs

8. An example of doing this at scale – Ethiopia’s Integrated Family Health Program In Ethiopia, PMTCT was added to an existing and strong FP/MCH platform • Program size and structure • FP/MNCH service delivery program in 286 districts of the four largest regions of the country reaching 80% of the population • Involves 10,000 community health workers and 223 health facilities that offer FP/HIV integration • Supervision and mentoring of health workers • FP services strategically target most at-risk populations, young women and married couples • The reporting is through the FP program. HIV reporting goes through the PEPFAR channel • Program services • Primary prevention of HIV • FP counseling includes STI and HIV prevention • Voluntary counseling and testing for HIV is integrated with FP • Prevention of unwanted pregnancy • Integrated services at the health facility level and community outreach • Treatment given to pregnant women • Antenatal and post partum care include family planning counseling • Treatment for women and their families • FP referrals at treatment sites • Community outreach by health extension workers promoting and offering family planning Results In the past 5 years, the contraceptive prevalence rate has increased from 13.6% to 29.3%

9. We are promoting a culture of evidence and quality in these programs Learning agenda priorities • Accrue an evidence base on integrated service provision • Carefully evaluate different approaches • Possible metrics include • Impact of integration on utilization of specific services • Satisfaction of staff and users • Cost • Adherence to service delivery and data collection protocols Challenge • Data on costs and effectiveness of integrated programs remains limited • Experience also limited so potential for unintended negative consequences of integration not well understood