Abstract

An integrated sexual and reproductive health package is widely regarded as essential for meeting the needs of both men and women. The practical realities of integration in KwaZulu-Natal, South Africa, were examined from the perspective of both providers and clients. Only minorities of clients received any assessment of reproductive and sexual health needs over and above their main presenting need or problem. The majority would have welcomed such assessments and many were classified as being in need, particularly for advice and services with regard to sexually transmitted infections, including HIV. Most providers were positive about integration, but their ability to practice an active form of integration was limited by inadequate training and time constraints. While training defects can be remedied, the time constraints posed by heavy patient loads are less tractable. More skilful use of booking clerks or the introduction of lay counsellors are also possible solutions.

Introduction

At the 1994 International Conference on Population and Development, 180 countries pledged support for the provision of comprehensive sexual and reproductive health services, delivered through integrated systems rather than by separate vertical programmes. Experience since then has been disappointing. While many countries have taken steps towards integration, political commitment has been weak and the pace of progress generally slow (Lush 2002). Little consensus exists about the optimal models of integration or about how best to achieve them, with the consequence that the term means different things to different stakeholders and takes a diversity of forms (Cates and Stone 1992; Lush et al. 1999; Foreit et al. 2002).

These uncertainties at the policy level have been compounded by practical problems of integrating services for curable sexual transmitted infections (STIs) and HIV into mainstream maternal and child health (MCH) and family planning (FP) services. The tools for effective diagnosis of STIs at primary health care level are still lacking, uptake of voluntary testing and counselling for HIV has been limited, drug therapy for HIV is only now starting to become available in the most affected countries, and condom promotion for dual protection has proved to be an uphill struggle, at least among married and cohabiting couples (Oberzaucher and Baggaley 2002; Maharaj and Cleland 2004).

Notwithstanding this myriad of problems, the justification for integrated services remains overwhelmingly strong in countries with severe generalized STI/HIV epidemics, and their potential contribution to HIV/STI control has been spelt out repeatedly (Pachauri 1994; Fox et al. 1995; Berer 2003; Askew and Berer 2004). MCH/FP services are often women's main, and sometimes sole, contact with the health care system and thus offer unique opportunities for STI/HIV information, advice and services. Moreover, the sound management of MCH and FP clients ideally requires information on their STI/HIV status and possible risks of infection. Increased availability of drug therapy for HIV and the advent of microbicides will further strengthen the case for effective integration of services.

The high profile of integrated sexual and reproductive health services in international debate has led to a growing body of evidence concerning practical aspects of integration at primary health care level, derived from operations research and descriptive studies of health facilities (Maggwa and Askew 1997; Dehne and Snow 1999; Solo and Maggwa 1999; Vernon and Foreit 1999; Mayhew 2000; Adeokun et al. 2002; Chikamata et al. 2002). However, the evidence base on the feasibility of different styles of integration is still extremely limited, and almost non-existent on their effectiveness and impact (O'Reilly et al. 1999; Askew and Maggwa 2002).

This paper documents the practical realities of integration in KwaZulu-Natal, South Africa, from both providers' and clients' perspectives. Information obtained from providers may sometimes elicit responses that reflect idealized rather than actual behaviour (Simmons and Elias 1994). For this reason, information obtained from providers is compared with that obtained from clients. The aim was not to assess the quality, effectiveness or impact of integrated services, but rather to provide answers to two main questions. The first concerns the extent to which providers initiate assessment of possible sexual and reproductive health needs of clients in addition to the presenting problem, by routine clinical screening or verbal enquiry into needs. This style of integration is characterized in this paper as ‘active’, in distinction to a responsive style in which clients have to take the initiative. The importance of this question stems from evidence that reliance on MCH or FP clients to report spontaneously concerns about, or symptoms of, STI/HIV infections (or MCH and STI clients to report FP needs) is clearly inadequate and makes little use of the opportunities presented by an integrated service (Dallabetta et al. 1998; Maggwa and Askew 1999). The published evidence on this topic is almost totally restricted to the proportion of FP clients who are exposed to STI/HIV information or advice (Miller et al. 1998). The second question addresses clients' demand, and need, for such an active model of integration, a hitherto neglected topic but nevertheless an extremely important one: if, for instance, most FP clients resent STI/HIV screening, or STI clients feel no need for FP information or advice, then active integration can never work.

The context

In 1994 the newly elected African National Congress (ANC) government was faced with the daunting challenge of transforming a fragmented and discriminatory health care system into one with the capability of delivering health care to all citizens, particularly those previously disadvantaged under apartheid legislation (Tollman and Rispel 1995). Since then the government has expended considerable effort on restructuring health services. One of the most notable changes was the creation of a single National Department of Health, which is responsible for strategic policy development and technical guidance. At the same time, nine provincial health departments were created and tasked with the responsibility for ensuring effective implementation of national policy (Department of Health 1997). As soon as the ‘new’ government assumed power, it also made free health care available for pregnant women and children under the age of six.

One of the foremost changes in the early years of the democratic government was the adoption of a district-based system, which is the principal instrument for the delivery of comprehensive integrated PHC services, in line with the Declaration of Alma Ata. The goal of the district health system was to achieve equity and improve access, effectiveness and efficiency of services through decentralized management services and localized service provision (Magwaza and Cooper 2002). The district health system is intended to function as a self-contained segment under the control of the local government. Districts have distinct administrative and geographical boundaries, incorporating all institutions and individuals providing health care (Lush 2000; Ndhlovu et al. 2003). The district health system builds on the principle of comprehensive care across a continuum, ranging from home and community care to specialized tertiary health care, and with an efficient referral network at each level (Department of Health 2002).

The first stage in the care continuum is home and community-based care. This involves self care as well as outreach programmes involving community health workers (CHWs), drawn from primary health care facilities or from the community itself, providing palliative and nursing care. The next stage in the care continuum is primary health care, which is the first point of contact with the formal health services and includes community-based services, services available at mobile/fixed clinics and community health centres. In addition, each district includes a community hospital at first referral level with the necessary laboratory, diagnostic and logistical support services. The district hospital normally receives referrals from and provides generalist support to community health centres and clinics. It therefore plays a key role in supporting primary health care, but is also a gateway to more specialist care. Next in the chain of care and referral is secondary health care, which provides more specialized diagnostic and treatment services. These hospitals receive referrals from and provide specialist support to the district hospitals. Tertiary health care encompasses more highly specialized services and typically includes provincial, national and specialized hospitals. Provincial hospitals receive referrals from and provide sub-specialist support to regional hospitals (Department of Health 2002).

Under the ANC government, commitment to delivering an integrated system of service delivery and management is strong, and explicit moves to integration have taken place (Lush 2000). In the past, FP in South Africa was to some extent a vertical programme, as were STI services. STI services fell within the scope of responsibility of local authorities, with little national coordination or standardization of STI preventive and curative services (Coetzee and Ballard 1996). One of the aims of integration was to bring previously separate and largely independent sexual and reproductive health service functions into a new single structure (Magwaza and Cooper 2002). At the primary health care level, the definition of integration has taken the form of a ‘one-stop’ supermarket approach, in which clients are offered a comprehensive range of reproductive health services (Lush et al. 1999; Department of Health 2000a). At the primary health care level, the integrated reproductive health care package includes contraceptive services (except sterilization), early diagnosis of pregnancy and delivery of normal pregnancy, antenatal care, growth monitoring, child immunization, nutrition education, abortion services, screening for breast and cervical cancer, the prevention and syndromic management of STIs and, to some extent, HIV education, counselling and testing (Department of Health 2000a; Ndhlovu et al. 2003). The integrated package of services is expected to be delivered at one location by the same staff. The training of providers reflects the emphasis on nurturing skilled generalists rather than specialists (Department of Health 1997). Clients may be referred to the next level for care when their needs fall beyond the scope of staff competence (Department of Health 2000a). At the district level, it is the responsibility of the local authorities to decide how services are implemented (Department of Health 2000a).

Voluntary counselling and testing (VCT) is a key entry point for HIV treatment, care and support (Oberzaucher and Baggaley 2002). However, in South Africa, VCT is a relatively new service, and as a result, the number of clients receiving these services is small (Ndhlovu et al. 2003). In 2001, implementation of the pilot programme for the prevention of mother to child transmission (PMTCT) commenced in two sites in each of the nine provinces. In 2002, the Constitutional Court of South Africa ruled that nevirapine should be available to all HIV-positive pregnant women who give birth in any public sector facility, and to their infants. Since then there has been a gradual expansion of the PMTCT programme beyond the original pilot sites (Doherty et al. 2003). At present, KwaZulu-Natal is in the process of ‘rolling these services out’ (Ndhlovu et al. 2003).

In 1996, the Choice on Termination of Pregnancy Act was passed which made abortion legal upon request by women prior to 12 weeks gestation. In their provincial study of KwaZulu-Natal, Ndhlovu et al. (2003) found that only 4% of facilities offered termination of pregnancy services. Health care providers in public hospitals and clinics in KwaZulu-Natal have refused to provide abortions, or to be trained to do so (Harrison et al. 2000). Although there is some information on the availability of reproductive health services at the national and provincial level, there is a need to assess progress in implementing policies for integrating services at the district level.

The study presented here was conducted in 2001 in KwaZulu-Natal, which is located on the country's eastern seaboard. The timing of the study thus predates the HIV testing and treatment initiatives described above. In 1998, the total fertility rate of KwaZulu-Natal was estimated at 3.3 children per women, contraceptive prevalence was 58% and the infant mortality rate was 52 per 1000 live births (SADHS 1999). KwaZulu-Natal has the highest level of HIV infection in South Africa. According to the 2001 national HIV survey, almost 33% of women attending state antenatal clinics in the province were HIV positive (Department of Health 2000b). The burden of curable STIs is also severe (Pham-Kanter et al. 1996; Wilkinson et al. 1999). In 2002, the STI incidence rate per thousand population was 77.7 in KwaZulu-Natal and 56.4 in South Africa (Department of Health 2003). The case for high quality integrated sexual and reproductive health services is thus particularly strong in this setting.

Methods

Two areas in KwaZulu-Natal – one urban, one rural – were chosen for the study. The rural area is situated about 85 kms, and the urban area about 15 kms, from Durban. In each area, there were four government health facilities and all were sampled for the study. In the rural area, these included two public health centres, one mobile clinic and a district hospital. In the urban area, the facilities were three public health centres and a hospital. This study was limited to government facilities because the vast majority of the population rely on the public sector for their health needs.

The methods used in the study were similar to those developed by the Population Council to assess availability and quality of services (Miller et al. 1997). Information was obtained by an inventory, key informant interviews, focus group discussions and semi-structured interviews with staff, and by exit interviews with clients. A range of methods was utilized to check consistency of information and also provide a detailed understanding of the process of integration from the perspective of clients and providers. The purpose was to obtain information about what services were integrated, and in what manner, and the implications for the delivery of services. The inventory was completed by observing the equipment and supplies that were available. In each selected health facility, one senior staff member was interviewed. These eight key informant interviews explored in detail the experiences of staff with integration and provided insights into the impact of national policies from the perspective of senior staff. Four focus group discussions were also held with providers at health facilities. The focus group discussions generated information on providers' experiences and the benefits and barriers to integration.

Semi-structured interviews with 40 providers offering FP, MCH and STI services were used to complement the information obtained from other sources. The providers interviewed had on average 12 years of experience. All but two of the providers were women. The semi-structured interviews explored the content of service provision, type of services offered, providers' attitudes, knowledge and professional practices. Topics canvassed with providers included their training, information about current screening practices, attitudes to discussing sexual matters with clients, and mechanisms for the integration of STI/HIV with FP/MCH services. The providers selected for the interviews were spread across all eight health facilities.

Exit interviews were held with 300 clients at the selected eight health facilities. The number of interviews per facility ranged from 28 to 48. The sample consisted of 100 FP clients (50 new acceptors and 50 re-visits), 100 clients of MCH services and 100 clients of STI services. These sample sizes were deemed sufficient for descriptive purposes. The key purpose of these interviews was to establish the extent to which clients were offered an active version of integrated reproductive and sexual health services as opposed to management of their main presenting problem or need only. Thus FP and MCH clients were asked in detail whether they received information about, or screening for, STIs including HIV. Similarly, STI and MCH clients were asked about receipt of FP information, counselling or services. Subjective measures of demand and more objective measures of need for active integration were developed. The subjective measures were based on answers to direct questions to ascertain whether clients felt they needed and would have welcomed advice or services of the specified type. In the case of family planning, the more objective measure of need was defined in terms of non-use of contraception despite a desire to avoid pregnancy for at least 12 months. The more objective measure of need for HIV-related services was defined in terms of a high or medium perceived personal risk of infection.

All clients were approached after they had completed their consultation with the provider and asked if they would be willing to participate in their study. Clients were given the assurance that their responses would be kept strictly confidential. Each interview lasted approximately 20 minutes. Recruitment of clients stopped when the pre-determined sample size had been achieved. The participation rate was 97%; very few refusals were encountered.

Fieldwork was performed by four specially trained field staff between February and April 2001. In order to gain access to health facilities, permission to conduct the research was first obtained from the provincial department of health in KwaZulu-Natal. Ethical approval to conduct the study was obtained from the University of Natal.

Analysis

The focus group discussions and in-depth interviews were tape-recorded and extensive field notes were compiled during fieldwork. A considerable amount of time was spent translating the tapes, reading the transcripts and developing preliminary codes according to particular themes. The computer package ‘Ethnograph’, was used to assist with data analysis. The data were organized according to advantages and disadvantages of integrated services. The transcripts are used extensively to illustrate particular findings and also provide some interpretations. The quantitative data obtained from the semi-structured interviews with providers and clients were entered using Epi Info and analyzed using SPSS. Descriptive analysis was conducted, which consisted mostly of frequency distributions and cross-tabulations.

Results

Observation and key informant interviews

In all eight health facilities, services are offered on a ‘one stop’ basis either by the same provider or by different providers. In four facilities, clients formed a single queue and saw one provider, regardless of need. However, in the other four health facilities, clients had to queue separately for specific services. Clients were more likely to form a single queue and see one provider in smaller rather than larger health facilities. In all but one facility, the full range of services was offered on every working day.

In all eight facilities, injectable contraception and condoms were in stock, and combined and progestin-only oral contraceptives were available in seven facilities. IUDs and female sterilization were not widely available. The IUD was available in three facilities and female sterilization was only provided at the two hospitals. Laboratory facilities for HIV or STI testing were available only in the two hospitals and routine syphilis screening of pregnant women was performed only at these two facilities.

Perspectives of providers

Some providers reported that they were initially resistant to integration because they had to handle their existing workload as well as new activities. Most of the resistance to integration came from providers who were accustomed to providing specialist services and, as a result, associated themselves with specific activities (for example, family planning). Under the integrated reproductive health package, however, providers were expected to offer a comprehensive range of services to clients. Providers reported that some of the earlier problems were overcome as they became more comfortable with providing integrated services. However, they observed that some confusion remained about what services should be integrated and how. As a result, in the absence of clear guidelines, senior staff reported that they had to rely on their own judgment for delivering integrated services.

Despite these teething problems, most providers expressed favourable attitudes to integration. Integrated services were acknowledged as serving the needs of clients more efficiently and effectively than vertical programmes and, as a result, are likely to contribute to greater client satisfaction. Moreover, clients have all their reproductive needs met at one service delivery site, which helps to prevent duplication and ensure greater continuity in services, as illustrated in the following quotation.

I think it is good that all services are provided by one provider. Often providers gain the confidence of clients and clients feel free to discuss their problems with the providers. They don't have to discuss the same problem with different providers. (urban, focus group discussion no. 1)

Another advantage of integration mentioned by several providers was enhanced confidentiality. In a single-queue system, no one except the provider knows the purpose of the visit and thus the stigma attached to STI patients or young unmarried FP clients is reduced.

People do not want others to know that they are receiving these services. For example, teenagers do not want others to know that they are using contraceptives. If everybody sits in one queue, only the health worker and the client know the reason for the visit. (urban, focus group discussion no. 1)

I do not think we should separate clients, because if this happens, STI clients may be stigmatized. If services are separated, people will say if clients are going there, it means that they have an STI. (urban, focus group discussion no. 2)

However, some providers felt that FP services suffer under the new integrated approach, which entails longer sessions with each client and this may sometimes lead to the loss of clients and longer waiting times.

Most health facilities have a shortage of staff. The integrated approach does not require many providers for the delivery for services. However, it does require that staff spend more time with each client. (rural, focus group discussion no. 1)

The problem is that we lose many FP clients. They leave before receiving their contraceptives because they don't want to wait for a long time before receiving services. If there were more staff, we could have a fast queue. (urban, focus group discussion no. 1)

Clients visiting health facilities are rarely offered a comprehensive range of services that will protect them against the twin risk of unwanted pregnancy and STIs/HIV. Lack of adequate training partially accounts for this finding. While 80% or more of the sample of 40 providers had received special training in child immunization, growth monitoring, antenatal care and FP, less than half had received similar training in STI diagnosis and treatment, and only one-quarter had been trained in HIV counselling or testing. The value of pelvic examinations in STI diagnosis was recognized but rarely performed unless requested, on the grounds that patients would object. Only 10 of the 40 providers claimed to practice syndromic management of STIs (i.e. based on clinical signs and reported symptoms). A slightly larger number based diagnoses on reported symptoms only, while over half said that they would refer the patient to another colleague or to another facility. Behavioural risk assessment was unpopular with most nurses. Some were uncomfortable at the prospect of discussing sexual matters with clients; others considered it to be an invasion of clients' privacy, claiming that clients would object to being asked a series of sensitive questions.

In KwaZulu-Natal, with its very severe HIV epidemic, condom promotion should be the centrepiece of integrated sexual and reproductive health services. Providers confirmed that demand for condoms had increased and condoms were acknowledged as a means of dual protection. Three-quarters of those who had provided FP services in the past 3 months claimed to have recommended condoms. At the same time, many providers were sceptical that condoms were a realistic option and cited resistance to their use by clients.

Women who come for STI treatment are encouraged to use condoms with their partners. However, women report that they are not able to convince their partners to use condoms. They complain that sex with a condom is not pleasurable. Men say that they can't eat a sweet wrapped in paper. (rural, key informant interview no. 6)

Most of the time clients use condoms for AIDS. We give them other methods of contraception and tell them that they don't provide protection against STIs but clients don't care. All they want is contraceptives. (rural, key informant interview no. 2)

In view of providers' discomfort with behavioural risk assessment and their scepticism about condoms, it is not surprising that most providers seemed better equipped and more comfortable with the traditional focus on FP and MCH. Effective implementation of a more active mode of integrated services was also hindered by a host of logistical problems. The common complaints by staff included insufficient space, high case-loads, lack of adequate staff preparation and training, shortage of equipment and infrastructure.

Client perspectives

Of the 300 clients, 81% were women, 84% were aged less than 30 years, 73% were neither married nor cohabiting, and 71% had at least one living child. All FP and MCH clients and 44% of STI clients were women. A large majority reported that the staff had been friendly, helpful and respectful, and 60% thought that they had received a good quality of service. The main complaints were unreasonably long waiting time (57%), inadequate privacy (23%) and insufficient time to ask questions (45%).

FP clients were asked whether the provider had discussed condoms. Providers were much more likely to mention condoms to new FP clients than to re-visit clients (56% versus 16%). Clients were also asked whether the provider had discussed dual method use. Less than one-third of clients said the provider had mentioned that condoms may be used in combination with other methods. Providers were more likely to have mentioned dual method use to new FP clients than to re-visit clients (54% versus 14%). To ascertain resistance to condom use, all clients were asked whether it would be possible to use condoms with their spouse or main partner, if advised to do so by a doctor or nurse: 67, 46 and 51% of FP, MCH and STI patients, respectively, responded positively.

FP and MCH clients were asked a series of questions to establish whether or not providers had initiated the topic of STIs and HIV or screened them for possible STIs and HIV infection by behavioural risk assessment, symptomatic diagnosis or clinical examination. Clients who received information about STIs invariably also received information about HIV/AIDS, and therefore answers have been combined. The results in Table 1 show that the topic of STIs/HIV was raised by providers in only 11% of FP consultations and 19% of MCH consultations. Behavioural risk assessment was attempted in 5% of consultations or less. Slightly more clients (6% of FP and 12% of MCH clients) were asked about vaginal discharge. Pelvic examinations were performed on 5% of MCH clients but on no FP clients.

Table 1.

Percentage of family planning (FP) and maternal and child health (MCH) clients who were screened in specified ways for sexually transmitted infections (STIs)

 FP (%) MCH (%) 
Number of sexual partners 
Partner's other sexual partners 
Client's concern about STIs 
Discussed STIs with partner 21 
Presence of vaginal discharge 12 
Pelvic examination performed 
Any of these topics 11 19 
100 100 
 FP (%) MCH (%) 
Number of sexual partners 
Partner's other sexual partners 
Client's concern about STIs 
Discussed STIs with partner 21 
Presence of vaginal discharge 12 
Pelvic examination performed 
Any of these topics 11 19 
100 100 

The results in Table 1 clearly indicate that providers in these eight health facilities made very limited use of the opportunity to raise the topic of STIs among FP and MCH clients, or to ascertain their requirements for related advice or treatment. But did these clients need such advice and would they have appreciated more active attempts by providers to offer an integrated service? Two approaches were used to address this question. First, FP and MCH clients were asked whether they needed (more) information or advice about STIs/HIV and whether they would have welcomed such information during the consultation. Those answering positively to both questions were classified as having a subjective demand. The results are emphatic: 68% of FP clients and 72% of MCH clients felt that they both needed and would have welcomed any (or more) information and advice about STIs/HIV.

The second approach represents a somewhat more objective measure of need. Following a short series of questions on sexual behaviour, clients were asked to assess their personal risk of infection with HIV as high, medium, low or no chance. Just under one-third (32%) of both FP and MCH clients rated their risk as high or medium and were classified as needing STI/HIV information, advice or counselling. Among those defined in this way as needing services, only 15% of MCH clients and 6% of FP clients had actually received any STI/HIV information or advice during the current consultation. Overall, 30% of FP clients and 27% of MCH clients were concerned about their risks of HIV infection, but received no relevant information or advice during their consultation.

To ascertain exposure of MCH and STI clients to FP information and advice, clients were asked whether any provider mentioned fertility intention, past use, interest in FP and so on. The results show that providers mentioned some aspect of FP in 26% of MCH consultations (Table 2). Typically clients were asked about their desire for children, ever use of FP and interest in using FP. In contrast, only 11% of STI clients were exposed to any aspect of FP.

Table 2.

Percentage of maternal and child health (MCH) and sexually transmitted infection (STI) clients who were asked questions to determine their family planning (FP) needs

 MCH (%) STI (%) 
Desire for children 13 
Desire to space between births 
Interest in FP 16 
Ever use of FP 13 
Concern about using any method 
Discussed FP with partner 
Any of these topics raised 26 11 
100 100 
 MCH (%) STI (%) 
Desire for children 13 
Desire to space between births 
Interest in FP 16 
Ever use of FP 13 
Concern about using any method 
Discussed FP with partner 
Any of these topics raised 26 11 
100 100 

The subjective measure of demand and the more objective measures of need for FP information, advice and services were ascertained in a manner similar to that described above in regard to STI/HIV needs. Overall, 58% of MCH clients and 56% of STI clients reported that they needed (more) information and would have welcomed it. The more objective measure of clients in need comprised those who were (a) non-pregnant, (b) not currently using any method, and (c) wished to avoid childbearing for at least 12 months. Under this definition, 14% of MCH clients and 18% of STI clients were classified as having a need for FP advice and services at the time of the consultation. Among this small number, 7% of MCH clients and 11% of STI clients had actually been exposed to any aspect of FP during the current consultation. Overall, 13% of all MCH clients and 16% of STI clients were in need of FP advice but received none.

Discussion

This study was conducted in a setting where the case for high quality integrated sexual and reproductive health services is particularly strong. Demand for contraceptive services is high, risks of HIV infection are among the greatest in sub-Saharan Africa and the burden of curable STIs is severe. Moreover, the main study population – clients attending one of eight health facilities in urban and rural KwaZulu-Natal – were predominantly young, sexually active individuals but as yet neither married nor cohabiting, and thus comprised a segment of the population that is at a specially elevated risk of unintended pregnancy and infection.

The results of the study are of special interest because South Africa has progressed further down the pathway towards the provision of integrated sexual and reproductive health services within the framework of primary health care than any other African country (Lush et al. 1999). Thus evidence from South Africa on the practical benefits (and limitations) of integrated services should be of direct relevance to other countries in sub-Saharan Africa with similar profiles of sexual and reproductive health problems.

Generalization of results to the whole province of KwaZulu-Natal (and even more so to the entire country) must be cautious because of the limited geographical scope of the study. For the four urban and four rural health facilities in the study, however, it is clear that at least a responsive version of integrated sexual and reproductive health services is a reality, in the sense that seven of the eight facilities offered FP, MCH and STI services together with basic curative care on a routine daily basis. Half of the eight facilities – typically those with a smaller number of staff – offered the purest or most extreme form of responsive integration, with patients in a single queue or waiting line and no specialization between staff. In the other facilities, a degree of specialization among staff was retained, with separate queues or clinics for FP, MCH and STIs. This link between size of facility and the precise way in which integrated services are offered is easy to understand and perhaps inevitable.

One of the more important findings of the study is that both providers and clients appear to welcome integration, at least in principle. Despite some initial resistance and uncertainty, providers were well aware of the advantages and convenience to the client of a ‘one-stop’ service. The enthusiasm of clients for integrated services was not ascertained directly but may be inferred from the fact that a majority would have welcomed more information and advice on sexual or reproductive health, in addition to the immediate need for which they had visited the facility on that day.

While staff commitment and a responsive clientele are no doubt essential preconditions for successful integration, integrated services are unlikely to be fully realised unless staff are trained in all major dimensions of sexual and reproductive health (FP, MCH and STIs/HIV) and feel comfortable in discussing these topics with clients. The results clearly show that the competence and confidence of KwaZulu-Natal staff in 2001 were tilted heavily in favour of the longstanding and familiar services of MCH and FP. Only a minority of staff had received training in any aspect of STI/HIV diagnosis, counselling or care. Proper syndromic management of STIs was poorly understood and rarely practiced. Routine syphilis screening of pregnant women was confined to the two hospitals. Pelvic examination of new FP clients for signs of infection was entirely absent. Moreover, providers were reluctant to enquire about risk behaviour of clients, using the justification that clients would resent such personal and intrusive questions, though providers' embarrassment is more likely to be the underlying reason. These results are consistent with the general verdict that STI services have been poorly mainstreamed into FP and MCH services in many countries (Lush et al. 2003; Askew and Berer 2004).

As stated at the outset, integrated services offer, in theory at least, an ideal opportunity for providers to assess whether clients have reproductive and sexual health concerns in addition to the presenting problem or need. The results in this regard are disappointing. Only a minority of consultations involved any attempt to raise reproductive or sexual health issues other than the presenting problem. High levels of STIs/HIV mean that clients need information not only about pregnancy but also disease prevention. In South Africa there has been little change in the available contraceptive method mix. Injectables continue to be the most widely practiced method of contraception by women (Cooper et al. 2004). Research continues to show that there is a need for more information about contraceptive methods, and concerns regarding particular methods need to be taken seriously by providers (Cooper and Marks 2001; Ndhlovu et al. 2003). In their study in KwaZulu-Natal, Ndhlovu et al. (2003) also found that the majority of clients were encouraged to use condoms, a critical prevention message in this high prevalence region. However, providers seldom mention specifics of condom use, such as the sensitive issues of negotiation and gaining partner cooperation. The low percentage of STI patients who received any FP advice can be explained partly by the fact that over half were men. Though in principle men should be counselled about FP, this topic is regarded in South Africa, by both men and women, as principally the woman's responsibility and providers' behaviour no doubt reflects this consensus (Maharaj and Cleland 2005). However, this consideration does not account for the low percentage of MCH and FP clients – all women – who received any STI/HIV advice. This evidence is consistent with other studies, which also found that reproductive health programmes are still thought of and implemented through separate channels (Ndhlovu et al. 2003; Richey 2003). For example, in her study in Tanzania, Richey (2003) observed a failure on the part of providers to raise the topic of HIV in their conversations with FP clients.

The implications of this failure of providers to practice active integration were assessed using both subjective and more objective measures. It is possible that the surprisingly high estimates of subjective unmet demand are inflated by social desirability bias. However, the fact that sizable proportions of clients expressed elements of dissatisfaction with the service they had received suggests that bias may not be a serious concern.

The objective approach led to the single most important result of the study: about 30% of both FP and MCH clients felt that they were at medium or high risk of HIV infection, yet received no information or advice on the topic of STIs/HIV. It may be concluded that providers are missing opportunities to inform and counsel women on an appreciable scale. The parallel estimate of missed opportunities to impart FP information is about 15%, much lower because most MCH and STI clients were already practicing contraception at the time of the consultation. Note, however, that this FP estimate is a lower-bound one, because it ignores possible problems with the current method and potential desire to switch methods.

Two main reasons may be discerned for the relative failure of providers at the eight health facilities in KwaZulu-Natal to address in an active manner the full spectrum of clients' reproductive and sexual health needs. First, as already mentioned, most staff were ill-equipped in terms of training to discuss sexual matters or to diagnose probable cases of infection. Adequate training of providers is essential for health facilities to be able to offer comprehensive, integrated services. In-service training and updated training, especially in the area of STI and HIV, should therefore be given high priority. Communication problems can be overcome with training (Adbel-Tawab and Roter 2002), though severe technical problems of STI diagnosis will remain pending advances in diagnostic techniques (Dallabetta et al. 1998; Sloan et al. 2000). The unavailability of anti-retroviral drugs at the time of the study may also have inhibited providers from addressing the issue of HIV, but the increased availability of drug therapy for HIV should make a positive difference.

The second reason is more pernicious and more intractable. Staff at the eight health facilities face heavy patient loads together with low morale, inadequate equipment, high staff turnover and other logistical problems, as has been found in other studies conducted in South Africa (Magwaza and Cooper 2002; Ndhlovu et al. 2003; Cooper et al. 2004). Under the pressure of a long queue, it is hardly surprising that most providers deal as efficiently and quickly as possible with patients' explicit needs before moving to the next patient. This emphasis on speed is understandable in view of the fact that the most common complaint by clients was excessive waiting time. Missed opportunities to address other related concerns thus stem to a large extent from the pragmatic but powerful factor of time constraints. Until this constraint is reduced, it will continue to thwart the full potential of integrated services to deal more actively and holistically with reproductive and sexual health problems. One possible strategy is to increase the average contact time between providers and clients by reducing administrative tasks. A study in three FP clinics in Zimbabwe found that providers spent only 40% of their time in client consultations and this allocation of time may also apply in KwaZulu-Natal (Janowitz et al. 2002). Providers in government facilities often try to finish service delivery by midday, leaving the afternoon for the more leisurely activities of record keeping (Miller et al. 1998). Thus, in theory, more time could be found for lengthier consultations. However, it may prove difficult in practice to alter working habits without the addition of incentives to do so.

Two other partial solutions could be considered. Systematic screening of the needs of all clients could be done by aides or booking clerks. This approach worked well in several Latin American countries, where it increased the number of services that the average client received on each visit (Vernon and Foreit 1999). An alternative is to make greater use of lay counsellors in recognition that many sexual health concerns only come to light after sensitive probing, which can be performed just as well – arguably better – by a layperson with good communication skills. How best to effect such a strategy would depend greatly on the local context and the willingness of government institutions to form partnerships with non-governmental organizations or volunteer groups. Ample scope exists for pilot projects to assess feasibility and cost-effectiveness.

Biographies

Pranitha Maharaj is a Researcher at the School of Development Studies at the University of KwaZulu-Natal, Durban, South Africa. Before joining the School of Development Studies she was a Lecturer at the Department of Sociology at the University of Natal, Pietermaritzburg. She has a Ph.D. from the London School of Hygiene and Tropical Medicine. She has researched and published on HIV/AIDS, sexual behaviour, family planning, condom use and men's reproductive health. Between 1998–2002, she was the principal investigator on the WHO study ‘Family Planning and Sexual Behaviour in the era of HIV/AIDS’.

John Cleland has been a Professor of Medical Demography at the London School of Hygiene and Tropical Medicine since 1993. Previously he worked for the World Fertility Survey and the Medical Department of Fiji. He has a masters degree from Cambridge University.

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Author notes

1School of Development Studies, University of KwaZulu-Natal, Durban, South Africa and 2Centre for Population Studies, London School of Hygiene and Tropical Medicine, London, UK