Integration and Expansion of Service Package

© 2014 George Obanyi/FHI 360, Courtesy of Photoshare

Sexual and reproductive health (SRH) services form part of the comprehensive health services package offered through any health system. To the extent possible, SRH services should be offered alongside other services that young people seek, including treatment and care for menstrual hygiene, anemia, mental health, substance use, injury, non-communicable diseases, HIV, post-abortion care, and maternal health. Additionally, where SRH services are provided, the broadest range of contraceptive options should be available to young people, including short- and long-acting reversible methods. These interventions are not specific to the urban environment, but have shown promise in increasing access to contraception for young people in a variety of contexts.

What Are the Benefits?

  • Increases access and convenience: A “one-stop shop” where young clients can receive multiple services reduces the number of facility visits, and lowers barriers to access
  • Maximizes available human resources at facilities; expands the number of providers who can offer contraception
  • Takes advantage of young people’s time and presence at the facility
  • Creates an opportunity to introduce contraception to new clients
  • Allows young people to seek SRH services under the cover of other curative services, reducing stigma and reluctance due to social norms

How to Implement?

Defining a Service Package

In low-resource settings, financial and infrastructure limitations may restrict health systems’ ability to provide “one-stop shops” for all the health services that young people need. While the full continuum of SRH services should always be available for young people through referral, many service-providing institutions opt to develop packages of “essential services” that meet the most urgent needs of their youth population. The process of determining the essential package should be undertaken in partnership with young people, including urban young people and marginalized populations. Below are examples of comprehensive and essential packages developed by different institutions.

Step 1: Familiarize yourself with national guidelines and packages of essential services for young people at different levels of the health system.

Step 2: Partner with young people residing in urban environments to define the package of services that would best fit their needs. 

Step 3: Discuss and decide upon the package of services that is feasible to provide, based on considerations of funding, facilities and human resources.

Step 4: Ensure a robust referral system is in place for all health services that are not available at your delivery point.

Expanding Method Mix

Even where a full range of contraceptive options is available, they are often not all offered to young people. Most commonly, information on long-acting reversible contraceptives (LARCs)  is omitted, in favor of short-term methods like condoms and oral contraceptive pills. This may be due to health professionals’ biases and misconceptions (such as believing that LARCs are not appropriate for young people), to inexperience (e.g., a provider who does not know how to insert intrauterine devices avoids offering them), or to legal restrictions on access to certain methods for young people (for example, in places where young people need parental consent to access LARCs). Professional opinions on LARCs are shifting, and they are now considered safe, effective options for women of all ages. The American College of Obstetricians and Gynecologists (ACOG), for example, advises sexually active adolescents who are at high risk of unintended pregnancy to consider LARCs as their contraceptive option (Advocates for Youth, 2012). The purpose of adding LARCs to the list of contraceptive options for young people is not for all young people to select those methods but, rather, to enhance choice and increase the likelihood that each client finds a method that fits her or his needs. Evaluations of programs for young people’s SRH in urban environments in Kenya and Bangladesh recommend the provision of LARCs as part of the contraceptive method mix to enhance choice and increase uptake of services (Huda et al., 2014; Mumah et al., 2014).  

Provision of LARCS as Part of the Contraceptive Method Mix

Global Consensus Statement: Expanding Contraceptive Choice for Adolescents and Youth to Include Long-Acting Reversible Contraception: Global efforts to prevent unintended pregnancies and improve pregnancy spacing among adolescents and youth will reduce maternal and infant morbidity and mortality, decrease rates of unsafe abortion, decrease HIV/sexually transmitted infection (STI) incidence, improve nutritional status, keep girls in school, improve economic opportunities, and contribute toward reaching the Sustainable Development Goals. We recognize and commit ourselves and call upon all programs promoting the sexual and reproductive health and rights (SRHR) of adolescents and youth to ensure full and informed choice of contraceptives, by:

  • Providing access to the widest available contraceptive options, including LARCs (implants and IUDs) to all sexually active adolescents and youth (from menarche to age 24), regardless of marital status and parity.
  • Ensuring that LARCs are offered and available among the essential contraceptive options, during contraceptive education, counseling, and services.
  • Providing evidence-based information to policymakers, ministry representatives, program managers, service providers, communities, family members, and adolescents and youth on the safety, effectiveness, reversibility, cost-effectiveness, acceptability, continuation rates, and the health and non-health benefits of contraceptive options, including LARCs, for sexually active adolescents and youth who want to avoid, delay, or space pregnancy

Integrating LARCs in Two Regions of Ethiopia

In the Amhara and Tigray regions of Ethiopia, the Evidence to Action Project and Integrated Family Health Program piloted a model of integrated service provision in 20 youth-friendly health services sites. The expanded service-delivery model included:

  • Competency-based provider skills training on implant and IUD insertion, removal, and infection control.
  • Refresher training for peer educators to counsel on safety and effectiveness of LARCs, to dispel myths and misperceptions, and to refer young people for services.
  • Supportive supervision for providers.

The findings of the study suggest that when providers are trained to provide IUDs and implants in a safe, competent way, young people may be more likely to adopt these methods (Population Reference Bureau, 2016).

Integrating Services

Step 1: Ensure that health providers possess the skills, competencies and attitudes to provide all health services on offer.

Step 2: Develop job aids, counseling cards or other resources to support health providers.

Step 3: Mobilize community support for the expanded or integrated service package for young people. 

Step 4: Make information, education and communication (IEC) materials that are youth-friendly; provide information on all services available; explicitly state that services are for young people.

Step 5: Use data, including feedback from young people, to refine approaches.

Step 6: Provide ongoing, supportive supervision for provider.


Integration with Maternal and Child Health (MCH)

Young people’s access to services can be sporadic. Health systems should capitalize on the key moments when young people do access health services, to provide them with contraceptive and other SRH services. One such moment is when young women (and young men) attend clinics or outreach services aimed at improving maternal and child health (MCH). Integrating SRH and MCH has been proven to save lives, money and time, including for first-time parents. Providing FP and MCH services together saves lives, money, and time by:

  • Lengthening the interval between pregnancies. One rigorous study, based on over 1 million births, found that if all women waited 36 months after a live birth before becoming pregnant again, the deaths of an estimated 1.8 million children under 5 years of age would be prevented annually (Population Reference Bureau, 2011).
  • Reducing the number of high-risk pregnancies. Helping women avoid pregnancies that occur too frequently, or too early or late in life, reduces deaths and disabilities among women and children, and saves health care and social service expenditures.
  • Ensuring health services are offered in an efficient and cost-effective way. Numerous costing studies demonstrate that a single, multipurpose FP/MCH visit can save the health system money by using common space, reducing staff costs, and lowering overhead. Broadening skills of personnel also helps ease the shortage of health workers.
  • Improving women’s lives and satisfaction with services. When women obtain different types of care in one visit, they reduce the travel time and expense of multiple visits and have more time to be productive.

A review of research and programs for first-time parents identified the integration of contraceptive and birth spacing counseling into maternal health services as a way to improve the quality of care from the perspective of young mothers (Greene et al., 2014). The findings state:

Antenatal and postpartum visits often provide the best opportunity to discuss contraception. Research has demonstrated the importance of providing contraceptive counseling to the mother during pregnancy and in the early postpartum period, as well as ensuring access to contraception, including long-acting and reversible contraceptive methods, as part of developing a life-long reproductive plan. Maternal health services can be an entry point for reaching young married women and girls in a way that is not threatening to other family members. An analysis of DHS data from 32 low-income countries found that women who have at least four antenatal visits are seven times more likely than those with no antenatal care to deliver at a health facility, increasing their chances of receiving contraceptive counseling both during antenatal care and postpartum care.


Integration with Post-abortion Care

Providing contraceptive counseling and services at the same time and location where women access services following induced or spontaneous abortion is categorized as a “high impact practice” (USAID, 2012). Young women disproportionately resort to unsafe abortion due to the barriers that they face in accessing safe abortion services across the world, including parental or caregiver consent requirements. Between 38% and 68% of the women treated for complications of unsafe abortion in developing countries are under the age of 20 (Skuster, P., 2013). The sheer number of young women accessing post-abortion care alone is justification for integrating contraceptive counseling and provision. Further, strengthening the contraceptive component of post-abortion care has been shown to increase uptake and reduce unplanned pregnancy and abortions in the future (USAID, 2012).

“If the woman we treat for post-abortion complications is there because she could not get contraception, we have failed her. If she leaves without family planning, we have failed her twice.” — Cynthia Steele Verme

Mozambique: Comprehensive Youth-Friendly Post-Abortion Services at Maputo Central Hospital

Building on the Ministry of Health’s and Pathfinder’s youth-friendly services (YFS) experience and Maputo Central Hospital’s comprehensive post-abortion care (PAC) services,Pathfinder/Mozambique focused on strengthening referrals and the continuum of care between five existing YFS sites and the hospital. Peer educators were taught how and where to access needed services and the importance of providing post-abortion counseling and contraception. At the community level, four youth associations were responsible for community mobilization and outreach to increase awareness of the right to treatment for abortion complications, places to access PAC services, and issues of service quality and access.


Integration with HIV Services

Programmatic evaluations have shown that integrated SRHR and HIV services improve access, increase uptake, and provide better care and increased efficiency in both time and resources. Some of the reasons for this are:

  • Both SRHR and HIV mainly serve reproductive-age populations;
  • Sexual and reproductive ill health and HIV share root causes, including poverty, harmful gender norms and inequality, cultural norms and social marginalization;
  • Both SRHR and HIV interventions have common desired outcomes, such as improved quality of life, gender equality and a reduction in maternal, newborn and child mortality;
  • Both SRHR and HIV interventions rely on community participation to address sensitive sexuality issues and sociocultural determinants of behavior change;
  • Both SRHR and HIV interventions are interested in addressing vulnerability, focus on behavior change, and use similar behavior change communication channels;
  • In resource-poor settings, both SRH and HIV services are typically offered through decentralised public health services. However, due to feared and actual stigma and discrimination, many key populations access health care provided through NGOs and trusted private healthcare providers (International HIV/AIDs Alliance, 2015).

Link Up Uganda

The Link Up project in Uganda has piloted a number of different SRH-HIV integration models in teenage health centers, community outreach, drop-in centers and HIV clinics. The results show that in providing a more comprehensive package of services in one place, young people have experienced a decrease in stigma and it saved them time and money. Providers were empowered by the integrated services’ ability to increase quality and more holistically address young clients’ needs.


Integration with Gender-based Violence

The changes in gender roles that may occur for women migrating to urban environments do not necessarily enhance their sexual and reproductive health and rights (SRHR), nor their access to justice. Evidence shows that in slums, women and girls are more vulnerable to gender-based violence (GBV) and poor SRH outcomes. The “Growing up safe and healthy” (SAFE) program run in the slums of Dhaka, Bangladesh attempted to address both of these issues through the provision of SRH and legal services; interactive sessions with men and women; and community campaigns. It was the first program in the world demonstrating a reduction in spousal violence.  SAFE shows that knowledge of laws – known as “legal literacy” – combined with knowledge of SRH and the existence of services can lead to better SRH outcomes as well as a reduction in GBV (Population Council, 2014).

Rights-Based Training for Health Providers

Dilaasa Project was established by the Center for Enquiry Into Health and Allied Themes (CEHAT) in 2001 in response to the need for comprehensive, youth-friendly support for young survivors of domestic violence. Since its inception, the project has been scaled up to 11 urban public hospitals in Maharashtra State, India. One focus of the Dilaasa Project is health provider training. The project’s training protocols address provider biases and integrate feminist counseling methods, empowering domestic violence survivors so that they recognize their own rights and can negotiate power dynamics. The approach focuses on the whole person rather than a public health approach of dealing with a clinical violation that has taken place. The goal is to create health providers who are champions for adolescent survivors within the health system.

CEHAT’s key insights from working with providers and counselors include:

  • Develop providers’ comfort with adolescent sexuality and adolescents’ comfort with their own bodies.
  • Ensure ongoing training and engagement with health providers to ensure capacity building, updated knowledge of legal protocols, and how to play a therapeutic role for adolescents with sensitivity. All of these combined contribute to shifting mindsets over time.
  • Integrate services for domestic violence survivors into existing services. While the Municipal Corporation of Mumbai initially wanted Dilaasa to be a standalone center, placing it in a hospital location was strategic as it helps to reduce the stigma of going to a SRH-specific clinic.
  • Engage youth in health seeking behavioral interventions in non-clinical settings - through comprehensive sexuality education, for example.
  • Develop specialized programs for adolescent girls and boys in health centers to encourage adolescent boys to report and talk about sexual violence. While there is an existing focus on talking to and working with adolescent girls, it is equally important to talk with adolescent boys.
  • Prioritize ethical documentation and standardization of the quality of counseling - both are critical to successful uptake and follow-up. This includes acquainting health providers with a survivor centric and feminist approach when working with counselors, the importance of debriefing among themselves and creating mentors between senior and junior health providers.

What Is the Evidence?

  • There is no medical reason to deny long-acting reversible contraceptive methods (LARCs) to young people (Advocates for Youth, 2012).
  • The World Health Organization’s (WHO) Medical Eligibility Criteria states that age alone is not a contraindication for any contraceptive method, including long-acting methods (WHO, 2015).
  • One study in Kenya found that voluntary continued use was higher among young women that had the option of having a contraceptive implant during their initial consultation (Hubacher et al., 2012).
  • Method mix is a human rights indicator related to quality and availability of services (WHO, 2014).
  • Numerous costing studies demonstrate that a single, multipurpose FP/MCH visit can save the health system money by using common space, reducing staff costs, and lowering overhead. Broadening skills of personnel helps ease the shortage of health workers (Population Reference Bureau, 2011).
  • Strengthening the contraceptive component of post-abortion care has been shown to increase uptake and reduce unplanned pregnancy and abortions in the future (USAID, 2012).
  • Programmatic evaluations have shown that integrated SRHR and HIV services improve access, increase uptake, and provide better care and increased efficiency (time and resources) (International HIV/AIDs Alliance, 2015).

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Helpful Tips

Youth Participation

  • Talk to a broad, intentionally diverse group of young people about their needs in order to define an integrated service package. Involve them in a needs assessment as co-researchers to get an honest understanding of service requirements in the area.

Data Management

  • Track service uptake by type and age and sex of clients to see which services are being accessed most and why.
  • Engage in regular qualitative client exit interviews to determine that young people have received the services they came for.

Multisectoral Collaboration

  • Partner with youth-led or youth-serving organizations that provide key health services (e.g., HIV, MCH) as well as other non-clinical or non-health services like mental health, legal or recreational services.

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Challenges

  • Integration and expansion of service packages for young people can be resource-intensive. Staff may also need additional training. These factors should be considered when determining whether and how to ensure young people have access to the best package of services for their needs.
  • Revisions in clinical procedures and protocols may be required; this, too, can be costly and time-intensive.
  • For MCH-SRH integration, an initial investment may be needed, although advocacy for integration should highlight that an initial investment in integration results in net savings as well as stronger training, management, and supervision of health providers.
  • Many young women do not access services at clinic-based service delivery points. Therefore, integration must happen for all service delivery channels, including outreach in urban areas. This will require training for outreach workers and other community health workers.
  • Population Reference Bureau points out that working across sectors can be a new experience for many donors and program managers with differing priorities; they may need to overcome concerns that integration will dilute attention and funding from the issue that matters most to them.

Tools Related to This Approach

Essential packages of services
Integration of SRH services

Related Approaches

References

See a listing of all AYSRH references.