1. Rationale for integrating MNCH & HIV global perspective PRESENTED AT THE NATIONAL MNCH/HIV INTEGRATION STAKEHOLDERS MEETING 24 TH SEPTEMBER 2014 AT GIRAFFE HOTEL DAR ES SALAAM, TANZANIA Dr. Anath Rwebembera Ministry of health and social Welfare National AIDS Control Program

2. Outline  Definition  Conceptial framework of MNCH/HIV Integraton  Principles  Rationale  Benefits  Challenges  Progress towards integration  Way forward  Conclusion

3. Definition Either:  Reorganization and reorientation of health systems to ensure delivery of essential interventions for HIV prevention, treatment and care as part of the continuum of care for women, newborn, children and families  Joining together MNCH and HIV services including referrals and operational programmes to ensure and maximize collective outcomes. This would from one service to another.

4. Definition  At service delivery level, to combining components of MNCH and HIV services that are currently delivered and managed separately, with the goal of maximizing coverage and health outcomes for the clients and optimizing the use of scarce resources.

5. CONCEPTUAL FRAMEWORK Policy, System and Clinical Service Delivery SRH KEYLINKAGES HIV Family Planning Maternal Health Management of STI Chill Health & Immunization RH cancer ARH PAC Prevention Treatment Care Support MNCH

6. Principles for Integration  Address structural determinants  Focus on human rights and gender  Promote a coordinated and coherent response  Meaningfully involve PLHIV  Foster community participation  Reduce stigma and discrimination  Recognize the centrality of sexuality

7. What’s the rationale?  Sexually active individuals face similar sexual reproductive problems including unintended pregnancies and HIV infection.  HIV in SSA significantly contributes to maternal mortality. Revealing that MDG 4, 5 and 6 are interconnected.  Universal access to MNCH services and to HIV prevention, treatment, care and support therefore have joint goals.

8. What’s the rationale?  Majority of HIV infections are sexually transmitted which are associated with pregnancy.  and the risk of HIV transmission and acquisition can be further increased due to the presence of certain sexually transmitted infections (STIs).  Majority of childhood HIV infection is through mother to child transmission during pregnancy, childbirth and breastfeeding;

9. BENEFITS of MNCH and HIV Integration  Improved access to and the uptake of key HIV and MNCH services  It expands the range of clinical services provided  Improves access for people living with HIV, young people and other underserved populations to SRH and HIV  services tailored to meet PLHIV needs and reduces stigma and discrimination

10. BENEFITS of MNCH and HIV Integration  Greater support for dual protection  Decreased duplication of efforts and competition for scarce resources  Mutually reinforcing and complementarities in legal and policy frameworks  Better utilization of scare human resources for health

11. BENEFITS of MNCH and HIV Integration  Integrating services increases the uptake of individual services and to access the hard to reach, including men and youth.  It may help overcome the challenges of inadequate male involvement, associated with stand-alone HIV/AIDS services.  To address missed opportunities in MNCH as well as HIV prevention and care across all service delivery levels

12. Some challenges Despite knowing the gains and evidence of integration, challenges still remain due to:  The early response to the epidemic was treated as an ‘emergency’ – just need to save lives  Early assumptions that “traditional” clients of MNCH services differ from the “most at risk” clients attending HIV services

13. Some challenges  Vertical donor funding streams  Parallel HIV and MNCH units/departments/programmes  The perceptions that HIV requires specialized training and specific skills that were outside the scope and remit of MNCH  The perception that HIV prevention and HIV treatment and care require two very separate responses,

14. Progress towards integration Despite a number of programmatic and policy challenges  Progress on advancing the linkages agenda has significantly increased.  Integration efforts are being supported globally through financial, technical and programme support

15. Progress towards integration Factors that have proven to promote linkages include:  Positive attitudes and good practices among providers and staff  An institutional commitment to ongoing joint capacity building  The active involvement of the community and government during planning and implementation

16. Progress towards integration  The addition of easily applied services which add very limited costs to existing services  The development of a ‘stigma-free’ environment in which services are provided  The involvement of male partners and engagement of key populations

17. Progress towards integration Factors that impede linkages include:  Non-sustainable funding to support increased work on linkages  Clinics that are understaffed and high staff turnover  Inadequate distribution of equipment, supplies and commodities which initially was vertical.  Supply chain management and logistic systems

18. Progress towards integration  Women insufficiently empowered to make SRH decisions; cultural and literacy issues  Adverse social events including domestic violence;  Stigmatizing attitudes that prevent a wide range of potential clients from utilizing services.

19. Specific findings from Tanzania On assessing status of integration in Tanzania some of the findings include:  Policies, plans and strategies supportive of integration are in place  At national level – MNCH and HIV units/departments still separate  At lower levels dispensary – More integration found compared district level, but still challenging

20. Specific findings from Tanzania  At service delivery level:  Integration ‘by default’ happening at primary health facilities – though not yet systematic  Positive perceptions from health providers (but fear of increased workload)  Infrastructure challenges to support integration  Human resource challenges to support integration  Commodity, equipment and supply shortages  ‘How to’ guidelines for providers just been developed

21. A way forward To strengthen current efforts towards integration and to mitigate the challenges, the following are proposed:  Ensure sustainable financing, harmonized policies and good practice  Address integration within and beyond the health sector  Strengthen ties between maternal and newborn health initiatives and relevant aspects of the HIV response

22. A way forward  Adress laws, policies, practices, stigma and discrimination that block access to integrated MNCH and HIV services  Maximize understanding and promotion of integration and in key population.  Promote and foster collaborative research to address the key research gaps in the integration agenda

23. A way forward  emphasize the importance of dual protection i.e. the use of male and female condoms - one method for protection against unintended pregnancy and against STIs and HIV infection

24. Conclusion  In this climate of harmonization, collaboration, increased accountability, declining financial resources and efforts toward reaching the Millennium Development Goals (MDGs) – there is political, financial and programmatic importance of integration of MNCH and HIV responses

25. THANK YOU FOR YOUR ATTENTION! ASANTENI SANA!