Service integration, focus on holistic healthcare improves health indicators

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Studies presented at the 40th Union World Conference on Lung Health in Cancun, Mexico earlier this month demonstrate that integrating health services can improve access to healthcare and health indicators by developing a patient-friendly approach in which multiple health issues are addressed in a single clinic visit.

A current USAID-AMPATH study integrates reproductive health services with HIV-related care for 75,000 HIV-infected patients at 23 clinics and 23 satellites throughout the Eldoret region of Kenya. Seventy per cent of these patients are women in their reproductive years.

Prior to the pilot programme, reproductive health and HIV services were run vertically, with separate clinics and appointments needed for each.



The cervix is the neck of the womb, at the top of the vagina. This tight ‘collar’ of tissue closes off the womb except during childbirth. Cancerous changes are most likely in the transformation zone where the vaginal epithelium (lining) and the lining of the womb meet.

pilot study

Small-scale, preliminary study, conducted to evaluate feasibility, time, cost, adverse events, and improve upon the design of a future full-scale research project.



The period of time from conception up to birth.

palliative care

Palliative care improves quality of life by taking a holistic approach, addressing pain, physical symptoms, psychological, social and spiritual needs. It can be provided at any stage, not only at the end of life.

loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

According to Dr. Rose Kosgei, the study’s lead researcher, the system presented many challenges for patients, specifically regarding the large number of clinic appointments needed to address each individual’s health needs.

Under the new programme, reproductive health and HIV services are co-located, with a central check-in and check-out point, an outreach service for those lost to follow-up, and one patient chart for both services. TB screening is also integrated with PMTCT services.

According to Kosgei, the programme’s “blend of vertical and horizontal integration” resulted in a 10.8% increase in reported condom use, a 7.1% increase in the use of contraception other than condoms, and a 1.3% decrease in pregnancy among the cohort.

While the p value of the pregnancy indicator was not significant, Kosgei believes it to be clinically significant, noting that researchers will also be able to better monitor the pregnancies of the women involved as the study continues. Women in the intervention arm of the programme were 27% more likely to use a family planning method than those receiving services under USAID-AMPATH’s non-integrated programmes.

More than two-thirds of patients screened for TB as part of PMTCT services presented positive tuberculin skin tests, demonstrating that a large percentage of the population is exposed to the bacterium and that more testing and treatment is necessary.

Kosgei also noted a “remarkably high level” of abnormal cervical exams, with 46 out of 150 women who underwent VIA screening requiring the removal of abnormal cervical tissue. Again this number indicates that further testing and treatment is needed to ensure better cervical health among this population.

As a result of programme integration in the USAID-AMPATH model, the number of clinic visits required by patients was reduced, says Kosgei.

A separate study conducted by the U.S. Centre for Disease Control and Prevention (CDC), based in Kenya and Malawi, integrated education and tools on safe drinking water, hygiene and sanitation with general healthcare services and antenatal care, again focusing primarily on women.

While the triple use of water disinfectants, safe water storage, and a focus on behaviour change, together termed “Safe Water Systems,” has been shown to consistently reduce diarrhoea by upwards of 85%, the use of such interventions is not widespread.

While most SWS use has been focused in homes, the CDC study introduced the programme to clinics. Says Dr. Rob Quick, a CDC researcher: “There are thousands of clinics in the developing world [that] don’t have safe water. These clinics cater to [vulnerable populations], such as those under the age of five, women, and those with HIV/AIDS.”

A pilot project in Homa Bay, Kenya, trained nurses, set up drinking water and hand-washing stations within clinics, and educated patients about the importance of clean water and hygiene. In order to assess intervention uptake, researchers conducted household surveys at 2 weeks and again at one year.

With 71% of patients’ drinking water presenting residual chlorine and 98% of patients able to correctly demonstrate hand-washing techniques a year after initial education, Quick considers the programme a success. He also notes that the project was cost-effective, with interventions costing less than $100 per facility and no extra staffing required.

A SWS programme at antenatal care clinics in Malawi demonstrated similar results, as did an intervention to include SWS in basic palliative care packages for HIV-infected people.

Quick notes that, due to such results, PEPFAR now supports SWS integration progammes and other “interventions that target multiple diseases.” The CDC plans for further SWS and healthcare integration in the coming years.


Kosgei, R. Integration reproductive health services into HIV care: experience from USAID-AMPATH. Presented at the 40th Union World Conference on Lung Health, 2009.

Quick, R. Scale-up of safe water and hygiene in MCH and HIV programmes. Presented at the 40th Union World Conference on Lung Health, 2009.