Integration: a Key Approach to Health Systems Strengthening

INTEGRATION: A KEY APPROACH TO HEALTH SYSTEMS STRENGTHENING

INTRODUCTION activities specifically targeting the SRH needs of Integration is an approach by which health care clients accessing various other types of services. RTP’s providers engage clients in addressing health and social strategic approach aligns with EngenderHealth’s global needs other than those prompting their visit to the commitment to delivering high-quality, sustainable health care facility. This type of service delivery can reproductive health care by increasing access to FP and take advantage of valuable opportunities by anticipating expanding choice for women and their families. services that are relevant to clients’ particular desires, needs, and/or risks (Farrell, 2007). BACKGROUND RTP is a five-year project (operating from 2012 through Integration offers the opportunity to provide 2017) that builds on the successes and lessons learned comprehensive care that addresses people’s holistic from the EngenderHealth-led ACQUIRE Tanzania sexual and reproductive health (SRH) needs. By Project (ATP) and the global RESPOND Project, also reaching clients at all points of care with messaging supported by USAID. RTP works toward the goal of and various services, such as those related to family advancing the use of FP and SRH services, with a focus planning (FP), providers capitalize on otherwise missed on the informed and voluntary use of long-acting opportunities to address those needs, maximizing reversible contraceptives (LARCs) and permanent use of providers’ time and resources. The Tanzanian methods of contraception (PMs). Ministry of Health and Social Welfare (MOHSW) Integration activities began in Tanzania in 2008 with the National Family Planning Costed Implementation MOHSW’s creation of the FP/HIV Technical Working Program, 2010–2015, has cited integration of FP with Group to coordinate national efforts toward integration other services as an essential strategy for achieving the of FP and HIV services. Since integration activities national goal of a 60% contraceptive prevalence rate by began during ATP, EngenderHealth has acted as the 2015 and a reduction in maternal mortality, as well as secretariat for the working group. Between 2009 and being instrumental in reducing the prevalence of HIV 2010, EngenderHealth collaborated with the MOHSW and AIDS in the country (MOHSW, 2008). to develop FP-HIV integration training modules for three types of FP service integration: FP at HIV care With support from the U.S. Agency for International and treatment centers (CTCs); FP into services for the Development Mission to Tanzania (USAID/Tanzania), prevention of mother-to-child transmission of HIV EngenderHealth, through the RESPOND Tanzania (PMTCT); and FP into provider-initiated testing and Project (RTP), implements bidirectional integration counseling for HIV (PITC) services. ACHIEVING HEALTH SYSTEMS STRENGTHENING THROUGH INTEGRATION RTP currently supports integration of FP, PITC, HIV care and treatment (CT), comprehensive postabortion care (cPAC), cervical cancer screening, PMTCT services, and gender-based violence (GBV) and violence against children (VAC) services. These activities cover five regions in Tanzania: Manyara, Iringa, Njombe, Mwanza and Shinyanga. RTP supports the MOHSW to build the capacity of service providers through trainings and supervision, improve quality of care, conduct minor renovations, and help facilities improve their client flow. RTP employs EngenderHealth’s five-step approach to integration: identifying the level of integration that can be adopted, assessing the health facility’s capacity Leonard Petro and his wife Matilda receiving FP counseling to support integration, building or strengthening that during a routine RCH visit. capacity, identifying the resources needed to support integration, and finally phasing in FP methods to Leonard Petro (23) and his wife Matilda (18) attend expand method mix based on the facility’s capacity. Misasi Health Center to receive pediatric services for their 2-month-old baby. During one visit to the FP INTEGRATED INTO REPRODUCTIVE AND facility, the young couple heard testimonies during CHILD HEALTH a health talk from satisfied FP clients. The couple received FP counseling on a range of methods and Since 2007, with support from USAID, EngenderHealth decided that implants would be the best option to has supported access to quality PMTCT services in help them space future pregnancies. Manyara Region.1 This support has continued under RTP, reaching 97% of health facilities (141 facilities) that provide reproductive and child health (RCH) services in the region. Twenty-two facilities in the To maximize points of contact, women and their region are supported to provide antiretroviral therapy partners receive FP information and methods (including (ART), and since services began, 181 HIV-positive postpartum minilaparotomy2) as part of regular services pregnant women have been enrolled in ART across at antenatal clinics, under-5 child health clinics, these sites. By June 2014, 100% of PMTCT facilities in and labor and delivery wards and within outpatient Manyara Region will offer Option B+, an antiretroviral departments at 135 RCH centers in Manyara Region. prophylaxis regimen for treating HIV-positive pregnant women and preventing pediatric transmission of HIV. FP INTEGRATED INTO CPAC SERVICES These comprehensive services have helped bring HIV RTP is supporting the decentralization of cPAC prevalence among babies down to 1%, from 23% services at 207 facilities in Mwanza and Shinyanga for in 2008. Beyond the facility, RTP works with local women experiencing abortion-related complications, organizations and other implementing partners to incorporated with FP services. Of the 6,043 cPAC increase awareness (especially among youth) around FP clients served at RCH facilities from October 2012 and HIV, including PMTCT. to December 2013, 5,046 (85%) were counseled on FP, and 4,090 of the women counseled (81%) were Nineteen PMTCT facilities are supported by RTP discharged with an FP method of their choice. to provide integrated FP services, so that pregnant women can make informed decisions about FP at antenatal visits and immediately following delivery and HIV CARE AND TREATMENT INTEGRATION counseling continues during delivery and postnatal In collaboration with the MOHSW and AIDS Relief, visits. From October 2012 to December 2013, 290 RTP trains service providers to offer FP within all CTCs service providers across all districts in Manyara Region in Manyara Region (26 sites). Preventing unintended were trained in LARCs and provided FP services to pregnancies among HIV-positive clients and HIV a total of 833 HIV-positive women. This represents transmission to children are critical steps toward an increase in the number of HIV-positive women improving maternal health and reducing maternal and accessing FP services, from 75 in October–December child mortality. 2012 to 259 in October–December 2013 (Figure 1).

1. From 2007 to 2012, EngenderHealth supported PMTCT efforts in Iringa Region as well. In June 2012, this support was handed over to Deloitte. 2. Minilaparotomy is a method of female sterilization.

2 PITC is also taking place as part of regular FP services at 15 supported facilities in Manyara Region. From October 2012 to December 2013, 8,621 FP clients were tested for HIV and received their results. The number of FP clients testing for HIV has more than tripled since this integrated service was introduced in Manyara Region, from 843 in October–December 2012 to nearly 2,700 in October–December 2013 (Figure 1). “We don’t plan to have more children, because now we are fighting for our lives… Being able to plan my family puts me at ease,” said Jumanne, an HIV-positive FP client who received PMTCT services with this wife at Magugu Health Center.

Figure 1. Number of clients receiving various types of integrated services, Tanzania, October 2012 to December 2013 Monika Elias (right) being counseled by Joyce Kapoli (left) at Misasi Health Center, an RTP-supported facility that 3,500 offers decentralized cPAC services. 3,000

2,500 Monika Elias (31), a mother of two living in Misasi District, was 12 weeks pregnant with her 2,000 third child when she began experiencing severe 1,500 abdominal pain and heavy vaginal bleeding. She 1,000 spent three days at home before her husband 500 insisted on bringing her to the nearby Misasi 0 Health Center, where she attends for RCH Oct.–Dec. Jan.–Mar. Apr.–June July–Sept. Oct.–Dec. 2012 2013 2013 2013 2013 services. Joyce Kapoli, an EngenderHealth-trained

No. of clients who received FP through other units cPAC provider, discovered that Monika had No. of FP clients who received PITC miscarried and quickly treated her via manual No. of PMTCT clients who received FP vacuum aspiration.3 “If women do not get No. of CTC clients who received FP treatment, they end up with severe complications. No. of PMTCT clients who received ART This procedure is quick and women feel good […] after the procedure and can be discharged,”

said Joyce. Before being discharged, Monika was INTEGRATING CERVICAL CANCER SCREENING counseled on FP and received a LARC to help her INTO RCH space her next pregnancy. Cervical cancer screening has been integrated into RCH and FP services at five hospitals in Manyara Region, starting in September 2013. Hospital managers have are identified through a national screening tool and been oriented on the importance of early detection were offered a comprehensive package of services, and treatment, and 18 service providers have been including: counseling, HIV PITC, screening for sexually trained on the use of visual inspection with acetic transmitted infections, cervical cancer screening, acid, an affordable and noninvasive test that can detect FP (including emergency contraception), and male precancerous cervical lesions. From September 2013 to circumcision. Providers work with GBV/VAC survivors February 2014, 1,408 women were screened, and 16 to develop a safety plan and refer them to higher level tested positive for precancerous cells and were referred authorities or health facilities. From January 2013 for treatment. to December 2013, 132 GBV/VAC clients received counseling on FP, and 45 were discharged with an INTEGRATING FP INTO GBV AND VAC CARE FP method of their choice. During the first year of RTP, FP was further integrated In collaboration with the EngenderHealth-led and into GBV and VAC services at facilities in target areas USAID-supported CHAMPION Project, gender in Iringa and Njombe regions. Since integration began sensitization activities facilitate male involvement in in January 2014, 7,545 GBV and VAC survivors were health care and reduce GBV. attended at 48 health facilities. GBV/VAC survivors

3. Manual vacuum aspiration (MVA) is a simple, low-tech method of treating incomplete abortions and miscarriages.

3 SCALING UP INTEGRATION EFFORTS RTP is building upon integration as a strategy for strengthening health systems and is providing technical assistance to the MOHSW for development and roll-out of the National Operational Guidelines for Maternal, Newborn, Child Health and HIV Service Integration in Tanzania. Together with the MOHSW and other partners, guidelines, policies, and curricula will be disseminated by the MOHSW to districts across Tanzania to promote national scale-up of integration. As part of standardizing quality of care, RTP is also collaborating with the MOHSW to conduct operations research for integration and aligning reporting forms and processes within integrated services, including referrals. RTP is currently conducting a baseline assessment of the needs and readiness of facilities in Manyara Region to further strengthen and expand integration of FP into a range of services. The results of testing a comprehensive integration model will inform scale-up in other regions.

CONCLUSION To offer a comprehensive package of services and address the holistic needs of clients, it is generally advisable and feasible to integrate FP with other services. Experience has shown that there is considerable need for FP information and services among a range of clients, especially those attending for services related to HIV and MCH services. Ensuring high-quality service delivery to these and other clients means integrating access to a range of solutions across the continuum of care. Not only do RTP’s integration activities create demand and meet needs for essential services, they also allow for health systems strengthening to occur in a more routine, cost-effective, and sustainable fashion.

REFERENCES Farrell, B. L. 2007. Family planning–integrated HIV services: A framework for integrating family planning and antiretroviral therapy services. New York: EngenderHealth/The ACQUIRE Project.

Ministry of Health and Social Welfare (MOHSW). 2008. The national road map strategic plan to accelerate reduction of maternal, newborn and child deaths in Tanzania. Dar es Salaam.

EngenderHealth • Plot #254, Mwai Kibaki Road/Kiko Avenue, PO Box 78167 Dar es Salaam, Tanzania • +255 (0) 22-2772365 www.engenderhealth.org

This publication was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the term of the Associate Cooperative Agreement No. 621-LA-13-00001 through LWA No. GPO-A-00-08-00007-00. The contents are the responsibility of EngenderHealth and do not necessarily reflect the views of USAID or the United States Government.