Progress on scaling up integrated services for sexual and reproductive health and HIV
Clare Dickinson a, Kathy Attawell b & Nel Druce a
a. HLSP Institute, 5–23 Old Street, London, EC1V 9HL, England.
b. Independent consultant, London, England.
Correspondence to Clare Dickinson (e-mail: email@example.com).
(Submitted: 06 January 2009 – Revised version received: 20 July 2009 – Accepted: 13 August 2009.)
Bulletin of the World Health Organization 2009;87:846-851. doi: 10.2471/BLT.08.059279
The importance of developing links between sexual and reproductive health and HIV services is widely recognized. Four priority areas for linkages – learning HIV status, promoting safer sex, optimizing links between HIV and sexually transmitted infection services and integrating HIV with maternal and infant health – could lead to significant public health benefits and improve efficient use of resources.1
This paper argues that, despite growing evidence that links between sexual and reproductive health and HIV services are feasible and beneficial, few countries have achieved significant scale-up of integrated services. It also looks at recent developments that represent opportunities to strengthen linkages and factors that impede progress. The paper follows recent usage of the term “linkages” as a generic description of links between policies, programmes and services.
Increased international commitment
This decade has witnessed greater commitment to sexual and reproductive health and HIV linkages (Table 1). More recent opportunities include policy developments within the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) to accept proposals that form linkages with sexual and reproductive health within the overall frameworks of HIV, tuberculosis (TB) and malaria. Also, there has been renewed commitment by the United States of America (USA) to international sexual and reproductive health through support of the United Nations Population Fund and the repeal of the Mexico City Policy, also known as the “global gag rule”, a United States government policy that prohibited nongovernmental organizations from receiving federal funding for performing or promoting abortion services in other countries.
Table 1. Key international commitments and developments supporting sexual and reproductive health and HIV linkages since 2001
Health systems strengthening
Greater financing of health systems strengthening to deliver universal access targets and the health Millennium Development Goals can potentially address health system constraints that currently hinder the scale-up of integrated services.
The Global Fund Five-Year Evaluation notes that 35% of approximately US$ 4 billion has been directed to key health systems elements such as human resources, infrastructure and monitoring and evaluation, with round 7 approving US$ 86 million for cross-cutting funds supporting health systems.7 Furthermore, the proportion of funds for health systems strengthening is likely to increase in the future through the Global Fund’s policy of national strategy applications from 2010.
Bilateral donors are also increasing resources for health systems strengthening and are prioritizing stronger linkages between sexual and reproductive health and HIV in the process. For example, the global AIDS strategy of the United Kingdom’s Department for International Development commits US$ 6 billion up to 2015 for services that integrate HIV, TB, malaria and sexual and reproductive health including maternal/child health services. AusAID, the Australian government’s overseas aid programme’s new HIV strategy promotes the integration of HIV services into primary health care and is strengthening linkages between HIV services and TB, maternal/child health and sexual and reproductive health services. The reauthorization of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) emphasizes a continuation of HIV treatment but plans to collaborate with programmes such as malaria, TB and maternal/child health.
While additional funding for health systems strengthening offers the potential to strengthen sexual and reproductive health and HIV linkages, there is currently little documented evidence or case studies of where this is happening. The recent Global Fund Five-Year Evaluation reports that integration of prevention of mother-to-child transmission with general maternal care services still needs considerable expansion of scope.7
Emerging evidence of benefits
There is a growing body of evidence that shows the potential benefits of strengthening these linkages. A systematic review of evidence, Sexual & reproductive health and HIV. Linkages: evidence review and recommendations,8 examined linkages between services and identified the benefits as: (i) improved access to and uptake of services; (ii) better access to appropriate sexual and reproductive health services for people living with HIV/AIDS; (iii) reduced HIV-related stigma and discrimination; (iv) improved coverage of sexual and reproductive health services in key populations; (v) increased dual protection against unintended pregnancy, HIV and other sexually transmitted infections; (vi) improved provider motivation and quality of care; (vii) reduced duplication of effort and competition for resources; (viii) enhanced programme effectiveness and efficiency; and (ix) better utilization of scarce human resources for health. The review concluded that linking sexual and reproductive health and HIV is feasible, especially in family planning clinics, voluntary counselling and testing centres and HIV clinics. Positive outcomes reported included improved access to and uptake of services such as HIV testing and increased condom use. Where the cost-effectiveness of integrated services was measured, there appeared to be net savings from integrating HIV (and sexually transmitted infection) prevention into maternal/child health services. As an indicative example, experience from Haiti suggests it is both feasible and beneficial to use voluntary counselling and testing services as an entry point to integrating a broader range of sexual and reproductive health services (Box 1).
Box 1. The Haiti experience of scaling up integrated sexual and reproductive health and HIV services
In Haiti, the GHESKIO (the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections) programme began by offering voluntary counselling and testing and treatment for opportunistic infections but has now integrated a wide range of sexual and reproductive health and HIV services. Voluntary counselling and testing has been used as a gateway to providing additional services that have been phased in over time e.g. diagnosis and treatment of sexually transmitted infections, diagnosis and treatment of tuberculosis, family planning services, antiretroviral therapy and maternal/child health programmes including prevention of mother-to-child transmission. GHESKIO has been an important driver of policy and practice, developing a model of integrated service provision that has been rolled out to 22 public and private health centres.9
Box 2. Joint task forces and working groups facilitate scale-up of services
In Kenya, PMTCT is integrated with antenatal care and other maternal/child health services. A PMTCT task force brings together HIV and sexual and reproductive health stakeholders and has facilitated the development of joint guidelines and protocols. Efforts to improve basic antenatal care services alongside introducing PMTCT have increased the number of new clients, acceptance of HIV counselling and testing and uptake of antiretroviral prophylaxis. The PMTCT working group in Zambia requires donors to support all elements of antenatal care. The PMTCT post funded by the Global Fund is based in the Reproductive Health Division, which is facilitating integration of PMTCT into maternal health services.
Box 3. Making the most of the money in Mongolia
Mongolia’s round 7 grant from the Global Fund focuses on two main areas: health systems strengthening and sexual and reproductive health integration with HIV services. Funding is supporting outreach services and peer education, including sexual and reproductive health education for commercial sex workers; integrating diagnosis and treatment of sexually transmitted infections with voluntary counselling and testing services; promoting condoms for dual protection; improving referral systems (in this case not all services are provided at the same site). Funding for sexual and reproductive health and HIV is provided through an integrated mechanism rather than through separate channels.20
Box 4. Health system weaknesses constrain scale-up
In Zambia, constraints to scaling-up prevention of mother-to-child transmission within maternal/child health services include shortages of staff, the need for regular in-service training at district level due to rapid staff turnover, and inadequate infrastructure in rural areas. Prevention of mother-to-child transmission and follow-up services are adversely affected by weak logistics in Malawi, where health workers report stock-outs of HIV test kits, nevirapine tablets and syrup and septrin.22
Experience of scaling up integrated services for TB and HIV highlight several important success factors. In this case, setting national targets for collaborative activities facilitates implementation and helps to mobilize political support and stakeholders’ engagement from both programmes. Creating a strong policy environment with appropriate policy and operational guidelines and training manuals has proved critical. Task delegation to front-line workers (such as capacity for HIV testing and counselling) and ensuring a regular supply of HIV test kits, drugs and commodities are also important factors (H Getahun, F Scano, P Nunn, unpublished data, 2008). Strong political leadership, effective national management and joint sexual and reproductive health/HIV policy and coordination mechanisms appear to be critical to building successful linkages. Kenya and Zambia have shown that, where there is strong commitment, progress can be achieved in scaling up prevention of mother-to-child transmission programmes through integration with mother/child health services (Box 2).10
Despite increased commitment and financing, scaling up linkages and integrated services has been modest. Some of the major impediments and progress in addressing constraints are discussed here.
Weak global governance
A powerful guiding institution for sexual and reproductive health and HIV is lacking. United Nations agencies have played a key role in providing technical support but until recently no one agency has emerged to champion these linkages. Linkages have been slow to develop institutionally, with documentation and guidance notes for countries only emerging since 2007. Progress is being made to address these weaknesses: in 2008 a WHO-led Inter-Agency Working Group on sexual and reproductive health and HIV linkages with participation from civil society, networks of people living with HIV, donor and United Nations agencies was established. This group aims to accelerate progress towards universal access targets through stronger engagement between sexual and reproductive health and HIV programmes, ensuring people living with HIV have access to the full range of sexual and reproductive health services they need.
Unclear definitions and scope
Unclear definitions have hindered progress, with policy and technical guidance referring to sexual and reproductive health and HIV “synergies”, “linkages”, “convergence”, “mainstreaming” and “integration”. This has not helped understanding or implementation. A related challenge is the wide range of services that potentially fall under the umbrella of sexual and reproductive health, making it difficult to define the scope of linkages. The Inter-Agency Working Group is developing a set of definitions, terms and indicators to promote greater understanding. One of the key lessons from the TB/HIV response has been the importance of developing globally accepted definitions, an agreed vision of “collaboration” between the two programmes and the practical meaning of “integration” of services at primary health care level. This crucial first step provided the platform for follow-on policy development and operational guidance and training for TB/HIV (H Getahun, F Scano, P Nunn, unpublished data, 2008).
Different perspectives and ideology
Experience from TB/HIV shows that, despite conceptual, practical and cultural differences between the programmes, stakeholders used the primary health care system as the platform for effective collaboration and delivery of integrated services, and stakeholders coalesced around a clear advocacy agenda of “dual epidemics” and the links between the two diseases. Finding a common platform between sexual and reproductive health and HIV actors has been more difficult.
Sexual and reproductive health is an area where different perspectives and ideologies have affected the provision of integrated services. For example, the implementation of the Mexico City Policy and the Global AIDS Act 2003 by the former Bush administration of the USA limited the capacity of HIV programmes to address the full range of needs of their clients with efforts focusing on less controversial services, such as family planning and voluntary counselling and testing programmes.11 President Obama’s overturn of the Mexico City Policy, the restoration of funding to the United Nations Population Fund, and a shift towards evidence-informed policy should help strengthen the enabling environment for linkages.
Negative attitudes and biases of providers towards people living with HIV also influence the provision of integrated services. Health-care workers may feel uncomfortable talking about sexual or risky behaviours to people with HIV who have same-sex partners, engage in sex work or inject drugs. As a result they may avoid discussing safer sex options or the wider sexual and reproductive health needs of people with HIV.12
International and national policy and programme responses have historically been separate. Poor representation of sexual and reproductive health stakeholders in national HIV policy and coordination structures such as national AIDS commissions and the Global Fund’s country coordinating mechanisms reduces opportunities to develop integrated policies and programmes. Separate or earmarked funding also reduces opportunities for linkages by making budgeting and accounting of integrated services difficult. The largest funding mechanisms for HIV, the Global Fund and PEPFAR, link their financial disbursements to targets and indicators that specify HIV-related outputs. This creates strong incentives to deliver “quick wins” and rapid coverage at the cost of longer-term horizontal approaches that strengthen health services but may be more complex to organize and manage programmatically.13
Some countries are making progress through the development of joint policies, task forces and cross-programme working groups. Greater emphasis on donor coordination processes would seem to strengthen arguments for the cost-effectiveness of pursuing linkages and offer potential to strengthen these linkages through greater alignment of national health and HIV plans, joint assessment processes and greater involvement of civil society in setting priorities for health and HIV plans. The Global Fund five-year evaluation underscored the need to accelerate efforts to harmonize, align and manage aid better. Growing pressure to fulfil the principles of the Paris Declaration on aid effectiveness14 and programme funds through less vertical approaches may potentially promote sexual and reproductive health and HIV linkages in the long term.
Recent funding trends show significant sums earmarked for HIV, while funding for sexual and reproductive health has declined in relative terms. Between 1995 and 2005, the HIV share of development assistance population funds increased from 9% to 43%, but for family planning fell from 55% to 23%.15 Financing for maternal health services is falling, according to a recent analysis for the Countdown to 2015 project.16
To date, funding for linkages and integrated services from significant donors such as PEPFAR has been limited.17 In the case of the Global Fund, a systematic analysis of elements of sexual and reproductive health in approved HIV proposals suggests that, although national level stakeholders see the opportunity for funding linkages, many missed opportunities still exist.18
However, countries are beginning to make use of international funds to support the scale-up of linkages. For example, Avahan, the US$ 330 million Gates Foundation AIDS initiative in India, is also supporting the Aastha Project which has developed a model for potential scale-up in which sexually transmitted infection clinics act as hubs for the provision of family planning and HIV services to sex workers.19 Countries are starting to use Global Fund grants for strengthening linkages (Box 3) and there is evidence that disease-targeted funding can have a positive impact on non-targeted health services. For example, data from Rwanda show a significant correlation between HIV interventions and improved antenatal care services and family planning.21
Health system weaknesses
Management and supervision of integrated services is more complex than managing vertical programmes, but these functions lack capacity in many countries. Health worker shortages, inadequate infrastructure and equipment and poor procurement and supply management systems are also significant challenges to provision and scale-up of integrated services (Box 4).
Provision of integrated services also places considerable demands on health workers but few receive appropriate training and technical guidance. Health workers may lack the confidence, skills, training and incentives required to take on new tasks or resent the extra workload resulting from the addition of HIV or sexual and reproductive health activities.
New sources of funding for health systems strengthening and support to sector-wide management processes represent major opportunities for developing comprehensive health sector responses to HIV as part of universal access commitments. Sector strategies can strengthen strategic and operational linkages between programmes and can improve coordination of health and HIV policies, human resources, procurement, supplies and infrastructure development in certain contexts.
Additionally, evidence is emerging about how HIV funds can strengthen health systems, which may influence the delivery of integrated services in the longer term. For example, in Ghana, HIV financing has enabled the Ministry of Health to allocate non-earmarked funds to increase staff and salaries of all health-care workers.23 In Ethiopia, disease-targeted funding has contributed to the production of a new mid-level cadre of health workers that provides not only HIV services but other services, such as maternal and child health, and has been integrated into the civil service.24
Renewed international commitment, increased financing for health systems strengthening and shifts in priorities of major funding organizations have the potential to strengthen linkages between sexual and reproductive health and HIV but it is still too early to assess the impact of these developments. Maximizing opportunities and addressing constraints require concerted action by donors, policy-makers and programme managers to: (i) promote a consensus and common understanding of these linkages; (ii) develop clear technical and operational guidelines on appropriate and cost-effective approaches to integrated programming in different contexts; (iii) accelerate dialogue and joint collaboration on policy, planning and implementation between actors including international donors and national bodies; (iv) ensure adequate resources for integrated service delivery within global funding mechanisms, national HIV strategic plans and health sector plans; and (v) continue to strengthen the evidence base, focusing on factors that promote linkages. ■
Funding: The HLSP Institute, London, England.
Competing interests: None declared.
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