The ICPD PoA’s concept of promoting and implementing STDs/HIV-AIDS programmes in integration with other major components of RH care programmes and services in the context of primary health care (PHC), is fully endorsed and supported by all Pacific Island countries (PICs). The PICs’ overwhelming support of this concept is based on several favourable factors including the following: every PIC has a sound and operational health care system and a functional PHC system; integration will shift the STDs/HIV-AIDS programmes from specialised clinic-based to a more holistic and cost effective approach especially at the PHC level; several components of RH care such as family planning, maternal health care (safe motherhood) child health care, human sexuality are already integrated and they all have similar target groups as those under the STD/HIV-AIDS programmes; employment of trained multi-purpose health care providers should be more cost effective than under the vertical programmes; better utilization of facilities, equipment and supplies; integration can reach more people especially women adolescents and youth on STDs/HIV-AIDS education and information; and screening programmes for STD/HIV-AIDS, breast and cervical cancers, and infant care and safe motherhood could be provided under ‘one clinic’.

Participants at the Programme Management Workshop during a group session

Limited success

Inspite of the presence of favourable factors that should have enhanced the move to integrate STDs/HIV-AIDS with other major components of RH care programmes and services, the progress has been very slow and not as successful as expected in several Pacific Island countries.

The PICs’ commitment to the promotion and implementation of the integrated approach as per ICPD PoA recommendations is unwavering. Every PIC is striving to operationally change its programme from the narrow spectrum of MCH/FP to the wider domain of RH care programmes and services. Training of multi-purpose RH care providers has started in most PICs. The introduction of the ‘syndromic management approach’ has enhanced the integration of STDs/HIV-AIDS programmes with family planning, MCH, infertility, management of the consequences of abortion and infant care at the PHC level. The programme on the prevention and control of STD/HIV-AIDS has been successfully integrated with other components of RH care in terms of information, education and communication (IEC) programmes in all PICs. Co-ordination among donor agencies and partners on RH is more visible. STDs/HIV-AIDS services are available at MCH/FP clinics/centres/hospitals at the Secondary/Tertiary levels. In this respect, a client can receive maternal care, screening and treatment for STDs/HIV-AIDS as well as cervical and breast cancer screening under one clinic. This is, however, confined mainly to the urban centres.

Constraints and barriers

There are major constraints hindering progress in integration. The term ‘integration’ is interpreted differently from country to country, leading to some difficulties in understanding and slowness in implementation. For example, most PICs’ health services are organised into secondary and primary health care levels (with very limited tertiary levels). Each level has a distinctive function in terms of policy setting, planning, budgetting, provision of services etc. As such, the application of the term integration in terms of administration, management and service delivery varies. Certain coordinators of individual programme such as MCH, FP, STDs, HIV-AIDS may be reluctant to integrate for fear of losing authority. Training of multi-purpose RH care workers is not as easy and inexpensive as previously thought due to the wide range of staff capability and skills especially at the PHC level. Unforeseen increased workload of multi-purpose staff has already led to demands for monetary compensation. On the other hand, the increased workload could also affect the quality of services.

The need to train more specialized staff at secondary/tertiary levels is still substantial. Refurbishing and upgrading of facilities and equipment will cost more. The RH needs of adolescents/youth are still neglected in some PICs, even under the umbrella of integration. Stigmatization of MCH/FP services if associated with STDs/HIV-AIDS still exists in some PICs. Men are still reluctant to patronise the programmes like MCH/FP and STDs to acquire condoms. Commitment to prioritization of the major RH/FP-SH issues of concern is still weak in some PICs. This leads to slow progress in the operationalisation of RH/FP-SH key components and subsequently the integration of services. Trained staff on STDs syndromic management are either prevented by law from carrying out this activity or not provided with appropriate supplies.

Disappointingly, in some PICs, HIV-AIDS programmes are not fully integrated with STDs. Some policy makers still argue that both vertical and integrated RH care programmes/services do have specific roles to play, hence, they should both be adopted. Commitment by PICs to change the current programme from MCH/FP to RH/FP-SH has been officially effected in only one country.

The way forward

A clear understanding of the term integration in relation to management, administration and service delivery, and its application to the local condition and environment is absolutely essential. Furthermore it must be noted that integration is not a strategy to fall back on when vertical programmes run out of funds or are unsuccessful. Government’s support to amend health policies and acts to accommodate the necessary changes associated with integrated RH/FP-SH services should be strengthened. Operational research is essential to assess the factors for failure or success in integration efforts. The results should be used to design new integration strategies to further improve the quality of integrated services, multi-purpose staff training, etc. It is important to reduce the high turnover of RH care providers, especially the specialists. The PHC infrastructure must be strengthened. It will make integration easier if RH care components are carefully and realistically prioritized and operationalized incrementally. The roles of the staff under the integrated programmes/ services must be clearly defined, bearing in mind that some will be more informed and skilful in STDs/HIV-AIDS, while others on MCH/FP, etc. As such, they should be encouraged to support and complement each other. The STDs programmes must be fully integrated with HIV-AIDS in all aspects as a necessary condition for integration with other components of RH care programmes. Cooperation must be strengthened among the key stakeholders. The RH needs of men, women and adolescents/youth should be given equal attention under the integrated programmes.

Programme Managers at the Programme Management Workshop during a group session

Perhaps the biggest challenge is to integrate the budgets along with programmes and services. From first hand observation and experience, when the budget is amalgamated or integrated, the programme is also easily integrated. Thus, everything from planning to evaluation, from budgeting to acquisition of equipment/ supplies, from training to provision of services, etc., should progress as designed and expected.

Expanded from the paper presented at the UNFPA Programme Management Workshop, 16-21 November 1998, Nadi, Fiji.