IMPROVEMENT ARE PIECEMEAL WITHOUTCOHERENT INTEGRATION and

VESTED INTERESTS IN STATUS QUO PROTECTS VERTICAL PROGRAMS

Integration is not something to add to primary health care, but is integral to its definition, i.e., the integration of curative, preventive, promotive and rehabilitative care. PHC addresses locally selected health problems with essential components such as maternal child health, immunizations, nutrition, local endemic disease control, water and sanitation, health education, essential medicines and basic curative care.

While the comprehensive and integrated nature of PHC was well established at Alma-Ata, the tendency has been to organize the disease specific projects and services according to the convenience of the health worker and/or vested interests of a donor agency. So instead of one MCH-FP clinic, separate child clinics, pre-natal clinics and family planning clinics are created. The following quote from a WHO technical report is pertinent to this position:

Multipurpose MCH services should not be isolated from other services, but integrated into a nucleus of basic health services. Combined maternal health and child health services are more effective and offer more opportunity for family care and health education and more efficient use of available personnel.

The present trend to integrate MCH services into basic health services rather than as a separate entity makes for more efficient coverage. The integration of MCH activities into local health centers will permit the development of a country-wide network to adapt MCH activities to local requirements and resources.⁽¹⁾

While this call for integration may be considered on the "cutting edge" today, it is important to note that the above quote comes from a 1969 WHO Technical Report. It makes one wonder what we have been doing for the past twenty-five years? The current development of the "integrated treatment of the sick child" is a renewed attempt to achieve this type of integration. The effectiveness of such an approach has been demonstrated in programs such as that conducted by Save the Children in Ethiopia (see Box 4).⁽²⁾

A good example of making a transition from "vested interests" to integration is provided by the Health Constraints to Rural Production (HCRP) project in Cameroon. Managed the Tulane University, the project began in 1984, and for several years was the only bilateral health project funded by USAID in Cameroon. HCRP developed a schistosomiasis research center in Yaounde to serve Francophone West and Central Africa, and trained a Cameroonian cadre to map the epidemiology of schistosomiasis.

These vested interests were set aside, however, in the Phase II of HCRP (1990-1993), which assisted the MOPH in developing and testing an affordable model for the control of schistosomiasis in highly endemic areas. HCRP II successfully developed, tested, and integrated components of health education, treatment, cost recovery and control strategies for schistosomiasis into the primary health care system. HCRP also produced a manual, Schistosomiasis Control in Cameroon,⁽³⁾ which includes a generic plan for the integration of schistosomiasis control into primary health care.

Box 4:

MCH INTEGRATION IN ETHIOPIA

Historically MCH services in Ethiopia were organized by different departments of the Ministry of Health as vertical programs. A mother and child were expected to attend the clinic on different days for curative care, growth monitoring, vaccination, antenatal care and family planning. Attendance at preventive activities was poor due to the distances that a mother and child must travel to get to the clinic. Family planning services were not well utilized since many women did not want to be seen attending a family planning clinic.

Save the Children Fund's began working in the Wollo Region of Ethiopia with a relief operation during the 1974 famine. SCF remained on to provide support to the regional hospital and EPI program. During 1988, SCF and other NGOs extended their role from the support of individual clinics to the provision of support to district health teams, in particular promoting integration of health services including MCH.

SCF agreed to help form the Dissie district health team to reorganize the health center to provide daily integrated health services. A systems approach was applied to design the new service which allowed the health worker to take a holistic view of the patient's needs. First the presenting symptom, or service requested, was dealt with, followed by the offer of preventive services such as growth monitoring, vaccination, antenatal care, family planning or health education.

It was possible to eliminate half of the forms of the existing record system with a simplified system of program registers and attendance/record cards. The health centers were also reorganized to make more effective use of staff time, making more time available for offering preventive services and enabling consultation in private.

The integrated clinics proved to be popular, and attendance of women and children increased. Vaccination and other services offered were readily accepted. A surprisingly high proportion of women, when offered family planning in private, requested it. A 263% increase in new family planning acceptor was registered during the year following reorganization of the health center. A 219% increase in tetanus toxoid vaccinations given to women occurred during the same period, while other vaccinations for children increased by 13-25%. These results suggest that the integration of curative and MCH services can contribute dramatically to improve maternal and child health.

back to OBSTACLES TO SYSTEMS STRENGTHENING

1. WHO Expert Committee on MCH. The Organization and Administration of Maternal and Child Health Services. WHO Technical Report Series, #428, 1969.

2. Walley, J.D. and McDonald, M. Integration of mother and child health services in Ethiopia. Topical Doctor 21:32-35, 1991.

3. Greer, G.J. Schistosomiasis Control in Cameroon: A Manual for Health Workers, New Orleans: SPH&TM Tulane Univ., 1993. pp. 1-68.