Guest bloggers Gavin Yamey and Craig Cohen report from last month’s Integration for Impact Conference in Nairobi, Kenya.
In many parts of sub-Saharan Africa, women have to go to separate clinics to receive the different health services they might need. For family planning, they go to one clinic. For HIV care, it’s a different clinic. If they are HIV positive, during their pregnancy they’ll receive antenatal care in one clinic but HIV treatment in a separate clinic.
Such fragmented services create major barriers for women, including additional travel, extra time taken off work, and having to wait in line again to be seen for the next service. For a woman who is HIV positive, having to disclose her HIV status to health workers outside of the HIV clinic could subject her to increased stigma and possible discrimination. And from a health system perspective, separating out different services for different health issues may be duplicative and highly inefficient.
Why not offer multiple services in a “one stop shop”—reproductive health and other services (e.g. HIV) provided in a single clinic with the same health provider during a single visit?
Such integration makes sense, and there is emerging evidence that it can be associated with a host of benefits, such as improved uptake of services, enhanced program efficiency, and even improved health outcomes when compared to separate services. For all these reasons, there is intense interest within the global health community in integrating services as a way to accelerate progress towards reproductive, maternal, neonatal, and child health (RMNCH) goals. Some countries, such as Kenya, are moving full speed ahead with national scale-up of integration.
What is the strength of the evidence on integration? Who is most likely to benefit? What are the costs in the long run? And what are the real world challenges and opportunities in integrating services in low-income settings?
Last month, in Nairobi, Kenya, these questions were explored at the Integration for Impact conference, co-hosted by the Kenya Medical Research Institute, the Kenyan government, and the University of California, San Francisco (UCSF) and attended by 349 participants from 30 countries. The emphasis was on presenting the latest research findings, exploring the policy implications of this evidence, and laying out the unanswered research questions.
Five key themes emerged:
1. Integration works but is not a panacea
A recent Cochrane systematic review on integrating HIV with RMNCH and nutrition services, published on the first day of the conference, identified 20 peer-reviewed intervention studies and concluded that integrated services “are feasible to implement and show promise towards improving a variety of health and behavioral outcomes.” However, none of these studies were randomized controlled trials (RCTs) and the risk of bias was high.
Fortunately, this review will soon need to be updated, because the first ever cluster RCTs of integrating HIV and RMNCH have now been completed. These were conducted in government health facilities in Nyanza province, Kenya, which has the highest HIV prevalence rate in the country.
One trial (registered here) examined integration family planning into the HIV clinic. The second (registered here) examined integration of three services into the antenatal clinic: antenatal care, prevention of mother to child transmission of HIV, and HIV treatment for the mother. PLOS ONE recently published the second trial’s design and baseline data, and the initial results from both trials were presented at the conference. The final results will be submitted for publication shortly. Both trials were associated with improved outcomes on some—but not all—outcome measures, adding to the growing body of evidence of the benefits of integration but also pointing to its limitations.
While there’s understandable excitement about integration, it is clearly no panacea. It cannot meet all of women’s unmet needs. There are still too few high quality studies showing its impact on health outcomes; indeed, most of the evidence to date has been on feasibility. For example, the Evidence to Policy initiative (E2Pi) recently summarized evidence showing the feasibility of two types of integration, HIV into MNCH services and cervical cancer screening into HIV clinics, and new data were presented at the conference on the feasibility of integrating screening for intimate partner violence into RMNCH services. Yet for all three types of integration, there have not yet been any RCTs. And there are limited data on the cost effectiveness of integration, a gap that is being addressed by the INTEGRA Initiative, a 5-year study in three countries on integrating HIV with sexual and reproductive health [SRH] services that is collecting cost data.
A particular concern is that the benefits of integration may be negated by HIV-related stigma. A recent study published in PLOS Medicine found that women in Nyanza province with higher perceptions of HIV-related stigma were less likely to deliver in a health facility with a skilled attendant. In the RCT of integrated antenatal services, stigma was associated with lower uptake of services in both the non-integrated and integrated trial arms. An important future avenue of research will therefore be on how best to incorporate anti-stigma interventions into integrated services.
2. We need to know which model works best for which setting
There are multiple models of integration, and it remains unclear which works best for which settings and which populations.
At the conference, there was much debate, for example, on the pros and cons of the “one stop shop” versus the “supermarket model” of integration (in which different rooms within a single facility offer different services but are tightly linked).
3. We must keep human rights at the forefront
The United Nations Population Fund (UNFPA) has made a bold declaration about the benefits of linkages between HIV and SRH, arguing that such linkages could reduce “AIDS-related stigma and discrimination” and improve “coverage of underserved and marginalized populations, such as injecting drug users, sex workers or men who have sex with men.”
But in a provocative plenary presentation, Kevin Osborne, Senior HIV Adviser at the International Planned Parenthood Federation, argued that the integration agenda has not yet lived up to these promises. Kevin is right—there is simply too little research being conducted on the role of integration in improving discrimination and in reaching underserved communities.
Bringing human rights to the forefront of the agenda will mean offering client-centered care, empowering people to demand services, working with the legal community to protect and strengthen human rights, and ensuring that underserved communities can reap the benefits of integrated services. It will also mean that we—as researchers, implementers, and policymakers—should address our gender biases when thinking about human rights.
4. We need to better define and measure integration
Research on integration has been greatly hindered by the lack of a standardized definition (what, exactly, is being integrated and at what level of the health system?) and of standardized monitoring and evaluation tools.
An important theme emerging from the conference is that it would be very valuable to have an “index of integration” that measures the degree of integration at the facility level. The INTEGRA Initiative presented its initial results on developing such an index, which has a range of attributes of integration, such as service availability in the integrated unit, the range of services provided daily, and the range provided in a single consultation.
5. Scale-up will require leadership, country ownership, and funding
Finally, the roll-out of integrated services will require leadership at the community, regional, national, and international levels. Advocates will need to focus their efforts on including integration in national plans and national budgets. Country leaders and ministries of health will need to take ownership and establish a “minimum package” of integrated services. And the donor community needs to step up to the plate. There is one donor in particular, the US President’s Emergency Plan for AIDS Relief (PEPFAR)—the largest single donor in support of HIV care, treatment, and prevention—that has so far failed to embrace integration, specifically in regards to reproductive health.
Gavin Yamey leads E2Pi in the Global Health Group at UCSF. Craig Cohen is a Professor In-Residence in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences; he is a Principal Investigator on the two RCTs of integration and co-author of the PLOS Medicine study on stigma discussed in this blog, and was an organizer of the Integration for Impact conference.
Competing interests: E2Pi has received funding from the Bill & Melinda Gates Foundation, which supported the Nairobi conference, funded studies of integration, and will be funding E2Pi to work on policy implications of the two RCTs of integration. Craig Cohen has received funding form the Bill & Melinda Gates Foundation, TIDES Foundation, U.S. Centers for Disease Control (PEPFAR), and the U.S. National Institutes of Health.