Preview Chapter 3

Introduction

This chapter provides a strategy for the integration of STD prevention and care activities into health care systems. The focus is on the circumstances needed for implementation and when it is necessary to add specialized approaches as well.

An Overview of Current STD Delivery Systems

Existing STD programs have not been very effective in increasing access and improving cost-effectiveness. The reasons include:

• Absence of a rational STD package
• Low priority by authorities
• Uncoordinated STD service delivery
• Specialized STD Treatment Facilities
• STD case management in primary health care: horizontal approach
• Private sector providers

Compelling Need for a New Approach

The appearance of HIV and AIDS, the pandemic of its fatal complication, have led to an urgent reappraisal of current STD control. Deficiencies must be addressed and strategies must be developed that transcend the limitations of past efforts. A six-step approach is proposed to change public attitudes about STDs, create a lower level of STD incidence and reduce STD complications.

Integration

An integrated approach proposes decentralized operational structure but with a central national unit responsible for research, technical guidance and materials. The focus of STD management would be at the district level.

Lessons Learned From Case Studies

• Strengthening Prevention and Management of STD/AIDS, Kenya
• The District STD Intervention Program in Mwanza Region, Tanzania
• Improving STD Case Management in the Jamaican Private Sector

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Introduction

This chapter describes a strategy for planning and implementing the integration of STD prevention and care activities into health-care systems. First, an overview of integration issues is presented. Second, current practices in STD service delivery and the disappointing results of different approaches to STD case management, including prevention, are discussed. Third, an integrated approach is described using the example of the district as the place where integrated services can be organized and implemented. (By a district we mean the most peripheral administrative area with some form of local government or administration where many responsibilities have been taken over from central government sectors.)¹ The focus is on the circumstances under which implementation can occur and where additional specialized approaches may still be needed. Finally, case studies are presented of small-scale integrated approaches that have shown early successes.

Over the past few decades, governments, health experts and care providers have used the word "integration" with a variety of meanings and in different situations. For some, integration may mean a new organizational structure merging various disease control programs. This may result in the fear that integration will bring a dilution of specific efforts in a system already too bureaucratic, and lead to endless delays in decision making at all levels. Those who have this fear believe instead that integration should mean regular coordination through information sharing among decision makers of existing programs.

Another view is that integration means adding tasks to unqualified and already overburdened staff, which leads to poor delivery of services. Those who share this fear argue that integration ought to mean a sharing of resources such as transportation among different programs.

Both views fail to appreciate that the aim of integrating specific disease control efforts is to enable the overall health program to provide appropriate services to more people at an early stage of disease development. This should be done in an environment in which educational and clinical activities can take place, referrals can be ensured, and patients can feel at ease. To achieve such an ambitious outcome, much more than coordination and sharing of resources is needed. Integration in this sense means that all health-care programs are responsible for and provide STD care as long as STDs remain a priority.

Integration of STD services into a decentralized and strengthened district health-care system is being proposed as an approach at the implementation level. The underlying principle of integration is a sharing of responsibilities by programs, units or departments and moreover by people involved in implementing health care at all levels.² Through such sharing of responsibility, broader access to STD prevention and care services can be achieved in an environment where stigmatization can be minimized,³ earlier access to services facilitated and easier continuation of services guaranteed. In addition, cost-effectiveness is enhanced through the provision of better services closer to those in need by more providers.

An Overview of Current STD Delivery Systems

So far the existing STD programs have not been very effective in increasing access and improving cost-effectiveness. Reasons for this lack of success are outlined below.

Absence of a Rational STD Package

As a result of the lack of authoritative guidance on a rational, practical and well-defined standard package of activities for STD prevention and care programs, the following has occurred at the implementation level:

• Little or no emphasis has been put on reducing risk behavior, preventing further infections and notifying partners
• Although resistance has developed widely to low-cost microbial agents, programs continue to use these antibiotics because they are available and inexpensive
• STD control efforts have concentrated on treating symptomatic patients (usually men) and have failed to identify asymptomatically infected individuals (often women) until complications occur.

Low Priority by Authorities

Donors and policy makers give low priority to allocating resources to strengthen STD control because of a lack of confidence in the effectiveness of health services. Other reasons for this low priority include:

• The association of STD with discreditable/immoral behavior
• Failure to associate STDs with their complications and sequelae
• Failure to recognize the magnitude of the problem

Uncoordinated STD Service Delivery

STD services have often been delivered through specialized public or private STD treatment facilities (clinics) that provide inadequate coverage at high costs and contribute to stigmatization, particularly for women. Existing public, traditional and primary health-care (PHC) facilities have so far failed to provide a first level of effective care with appropriate referrals because of poor management, inadequate support and lack of sensitivity to STD clients' needs.

Specialized STD Treatment Facilities

In some countries, STD control is based on the belief that only categorical or special STD clinics can provide the necessary quality case management. Examples of these model STD clinics can usually be found in towns or cities, often located in major hospitals or affiliated with university hospitals. Physicians with specialized training are meant to provide care for patients referred because of complications or particular difficulties, but in reality see mostly first-contact patients.

Usually these programs are highly centrally organized and coordinated from a special unit in the ministry that takes full responsibility for implementing national STD control activities. Financial management, supplies, drug distribution systems, training plans, staff allocation, and reporting and supervisory systems are all directly controlled by the central unit. These specialized clinics are particularly well suited to offer training opportunities in STD case management.

Quality of medical care provided is usually high but very staff- and resource-oriented. These types of STD programs tend to promote their own parallel organizational structure by establishing a system of special clinics to reach the more peripheral levels of the health-care system. For example, within such a program at the district level, one can find STD outpatient clinics with special staff, supplies and records. Because these clinics are easily identifiable, stigmatization of clients as common.

In the past, governments, funding agencies and donors have promoted such a vertical approach for a variety of reasons. Many believe that this approach results in more efficient case management. Another reason, however, is that centralized control and tight accountability of how finances are spent enables governmental and nongovernmental organizations to satisfy donor demands to link expenditures with specific measurable outcomes.

The advantages and disadvantages of this vertical approach are summarized in Table 1.

STD Case Management in Primary Health Care: Horizontal Approach

In programs where STD case management is integrated into primary health care, a first outpatient contact between a care provider and an STD care seeker can result in direct STD case management, leading to high coverage. STDs can be diagnosed and treated at any level or site of the public health system, be it a village dispensary, a health center, a maternal and child health (MCH) or family planning (FP) site, or an outpatient clinic at any hospital. General health-care providers with their basic training and sometimes with refresher STD training can provide treatment for uncomplicated cases of discharges and genital ulcer diseases. Only complicated conditions need to be referred.

Laboratory support is requested from the existing laboratory system at that site. The quality of care, including the use of available essential drugs and laboratory support, is supervised by the local clinician responsible for that site. At the national level, technical guidance and coordination can be provided by the units responsible for peripheral health-care services and essential drug supplies. This approach is often promoted under the programmatic umbrella of primary health care.

Although this horizontal approach offers the potential for improved access, prevention and cost-effectiveness, its implementation by Ministries of Health (MOHs) has suffered. This is due to several setbacks resulting from the overall decline in socioeconomic development in many parts of the developed and developing world. In addition, over the last 10 years very few funding agencies or bilateral donors have committed themselves to assisting MOHs in improving overall health infrastructures and supporting operating costs. As a result, district and peripheral health staff are demoralized, unsupervised and underpaid. Facilities are not maintained properly and essential drugs and other supplies are not regularly available.

Since diagnostic supplies and available antibiotics often do not match the need for STD treatment, confidence in the health system is lost, attendance drops and alternative services are used. In particular, unaccredited providers with poor training or no training at all have filled the demand gap. Inadequate treatment has resulted in the development of drug resistance and disease sequelae. In addition, these alternative services place no emphasis on prevention.

Private Sector Providers

In addition to specialized and integrated government programs, other sectors provide much–if not most–of STD care. These private providers may operate officially (licensed) or as unlicensed practitioners (see Table 2). Both are widely accepted and utilized.

In order to improve the quality of STD services, the private sector should not be ignored. In many countries, it provides a significant amount of STD care, although the care is often inadequate or inappropriate in clinical aspects and, in particular, lacks the emphasis on preventive aspects. The challenge for STD control programs is to ensure that coordination occurs with the official providers and that patients are diverted from unlicensed providers.

Compelling Need for a new Approach

STD incidence in the world is unacceptably high as a result of ineffective treatment and limited STD prevention and care activities. In practice STD prevention and care often consist of a quick STD history taking and a prescription for treatment. As a result, most care givers miss the opportunity to help prevent further transmission.

The rapid appearance of a new sexually transmitted infection, the human immunodeficiency virus (HIV), and the pandemic of its fatal complication, acquired immune deficiency syndrome (AIDS), have led to an even more urgent reappraisal of current STD control. Early STD disease detection by health staff and appropriate treatment can substantially reduce STD incidence and prevalence, and also lower the risk of transmitting or acquiring HIV.

To address these deficiencies, an appropriate intervention would include:

• Promoting health-care-seeking behavior directed particularly toward those at increased risk of acquiring STD, including HIV infection (see Chapter 13)

• Providing rational diagnosis and effective treatment for curable symptomatic and asymptomatic patients with STD and their partners (see Chapters 8 and 11)

• Promoting safer sexual behavior, including condom use (see Chapter 10)

• Providing condoms at affordable prices (see Chapter 5)

To translate these objectives into a practical, feasible program, one would aim for broad community acceptance. Ideally, this program would be part of community health services, which would offer this package of preventive and curative measures. The implementation steps for a new approach to STD intervention, which will be provided by all care providers and serve all in need, are shown in Figure 1.

These first three steps should be combined as an intervention package. A training module should be developed and workshops organized to teach PHC staff at the district level how to use a syndromic flow chart. In addition, sufficient refresher materials and wall charts should be left behind in each PHC facility.

• Step 1. An effective intervention would use the syndromic STD approach described in Chapter 8 (technical efficacy of STD intervention).

• Step 2. People with STDs need to be aware of the importance of early treatment and be able to recognize their symptoms in order to seek health care. Clinicians need the diagnostic and communication skills to make decisions based on flow charts of syndromic approaches (identification of all persons in need).

• Step 3. To apply a syndromic approach, clinicians need the appropriate flow charts and a regular supply of drugs, as well as referral possibilities (availability of intervention).

Steps four through six aim to extend the coverage of health services by ensuring that when people recognize symptoms, they will come to a health facility promptly, possessing the confidence that the facility's staff members have been able to build.

• Step 4. The syndromic approach should be integrated into a care system that is easily accessible to those in need. Accessible means both affordable and conveniently located (accessibility of services).

• Step 5. Health services must be accepted and liked by men and women in the community. This is particularly important for STDs, because feelings of stigmatization are common. Well-organized services and positive attitudes among staff members will ensure that services are used (utilization of services).

• Step 6. Committed care providers should emphasize the need for adherence to a full treatment course and continuing care, including partner notification and proper follow-up (compliance of provider and user).

If all these steps are given adequate attention in the implementation process, a successful community health impact could be expected. This approach can lead to a reduction in STD complications or even a reduction in STD incidence within the community using the health-care facility. If implementors focus on only one or two steps but not on the whole process, a positive impact on the health of community members is very unlikely (step 7, community impact). Process indicators can be identified for each step in order to measure the progress made at regular intervals, such as every three months. These indicators form the base of the monitoring system for the services.⁴

Integration

In order to reach the largest possible population in need, these interventions must be offered at sites that are easily accessible to patients. In providing both prevention and care interventions on-site, an appropriate balance between face-to-face educational and clinical activities will have to be maintained. Coverage and quality are thus the cornerstones of this integrated approach to STD care and prevention. This emphasis is designed to avoid the pitfalls of current practices and boost confidence in the STD services.

Key elements of one such integrated approach would include:

• Shared responsibility by all health-care providers, particularly at the district level

• A decentralized operational structure that gives district health teams the authority and means to coordinate and supervise the STD prevention and care activities of public and nongovernmental providers

• Syndromic diagnosis at first-level contact based on a "package" standardized through in-service training of all health-care providers

• A strong emphasis on face-to-face education during any contact

• A cost-effective approach to service delivery through cost-recovery measures

The strengths and weaknesses of the steps in STD case management implementation for each of the various existing approaches to STD case management are compared in Table 3. This comparison illustrates how the proposed integrated approach could result in strengthened comprehensive care management and wider coverage.

With this decentralized, integrated approach, a central national unit responsible for developing training materials, ensuring technical guidance and initiating relevant research would be maintained. Specific referral sites would be developed encompassing STD clinical expertise, training and research.

The focus of STD management would be at the district level, where a district health management team consisting of public and nongovernmental health planners and managers would be responsible for coordinating STD prevention and care. This team would ensure quality control at all relevant contact points for people in need of STD services, such as hospital outpatient clinics, MCH/FP clinics, dispensaries and health centers. If such a management team were strengthened and had the authority to operate, it would then be feasible to maintain close contacts with private sector providers to guide them on comprehensive approaches and initiate relevant in-service training. These would include:

• Seminars through local medical associations to improve knowledge and skills in STD management
• The sharing of guidelines
• A centralized lab used by both public and private sectors
• Linkages to condom programs
• Referral services
• Pharmacy training

Lessons Learned From Case Studies

References

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2. Matomoura MS, Lamboray JL, Laing R. Integration of AIDS programme activities into national health systems. AIDS 1991;5(suppl 1):193—196.
3. Fransen L, van Dam CJ, Piot P. Health policies for controlling AIDS and STDs in developing countries. Health Policy Plan 1991;6:148—156.
4. STD case management training as part of an STD control programme. Geneva: World Health Organization/Global Programme on AIDS, 1994.
5. Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania. Lancet 1995;346:530—536.