Francesca Stuer, Medhanit Wube, Tamrat Aseefa - Home and Community Based Care, Family Health International, Ethiopia
Medhanit Wube, MPH, RN, is currently working as Home-Based Care Team Leader for FHI in Ethiopia. She has more than 10 years experience in reproductive health and maternal/child health program leadership, research and technical assistance, and has more recently started working in the fields of HIV/AIDS and integrated FP/HIV. She leads the FP/HIV integration efforts of more than 14 community-based programs in Ethiopia and facilitates their coordination with public health facilities and regional as well as district health authorities.
Tamrat Assefa, MPH, RN, is currently working as FP/HIV Integration Coordinator for FHI in Ethiopia. He is specialized in public health, social research on HIV vulnerability, care and support, and has extensive field experience in Ethiopia. His professional activities have focused on capacity building of both the governmental and non-governmental sectors in the fields of HIV/AIDS service delivery at facility and community levels, behavior change communication, maternal and child health, integration of FP and HIV, monitoring & evaluation, and operations research. He is also a member of the Addis Ababa Reproductive Health Leadership Network.
Francesca Stuer, MSc, RN, currently serves as Country Director for FHI in Ethiopia. Ms. Stuer is a health program management specialist with a strong background in public health programming and nursing. She has more than 13 years experience designing and managing successful large scale public health projects in Ethiopia and Cambodia. In Ethiopia, she leads FHI's public health and social welfare development programs which include technical assistance and operational support for HIV/AIDS prevention, care & treatment, and integration of FP and HIV, as well as operational research in child care and other public health areas.
The HIV/SRH Integration site interviewed Medhanit, Tamrat and Francesca about Family Health International's provision of integrated services in Ethiopia.
Can you provide background information on the HIV/AIDS and sexual and reproductive health situation in your country?
Ethiopia's diverse population of 77 million - the second largest in sub-Saharan Africa - is predicted to grow by 2.75% annually through the year 2025. Population growth is a major problem in Ethiopia. The current contraceptive prevalence rate among married Ethiopian women is 15%, and among all women of fertile age is 10.3%. One in three currently married women has an unmet need for family planning (34%). Family planning (FP) is delivered through facility-based reproductive health (RH) services, including government health facilities and health services run by Marie Stopes and the Family Guidance Association of Ethiopia (FGAE); through pharmacies selling socially marketed pills, condoms, and Depo-Provera; and by community-based reproductive health (CBRH) agents engaged by NGOs and CBOs.
Ethiopia is seriously affected by the HIV/AIDS epidemic. While the 2.1% single point estimated national prevalence rate (harmonization of DHS 2005 and MOH 2005-ANC data) is lower than those of most East African and all southern African countries, the large size of the Ethiopian population ranks this country among the most afflicted countries in terms of total number of cases. Although the urban rate appears to have started declining - perhaps brought about by real behavior change - it remains at the alarmingly high level of 7.7%. The rural HIV/AIDS prevalence rate seems to have leveled off at 0.9% in 2005. Around 1 million Ethiopians are thought to be living with HIV/AIDS, of which the majority are female. Estimates from the same year indicate that the number of children orphaned by AIDS totaled 898,350. More than 64,000 children are estimated to be living with HIV in Ethiopia today. There are more than 14,000 new infections among children annually. While over 90% of children acquire HIV from their mothers, to date only 1.15% of HIV-infected pregnant women in Ethiopia received antiretroviral therapy (ART). Despite efforts to scale up Prevention of Mother-to-Child Transmission (PMTCT) services in the country only 16% of the antenatal care (ANC) clients were tested for HIV in 2005/6, and 52.9% of HIV- positive women and 32% of babies received Nevirapine prophylaxis. In that same year, 0.8% of HIV infections among children born to HIV positive mothers were averted through PMTCT. The low PMTCT coverage is due in part to limited access to reproductive health services, extremely low institutional delivery (2-8%), and low ANC follow up (25-50%).
Please tell me about a project /program experience integrating HIV/AIDS and sexual and reproductive health services.
To date the integration of HIV and FP services in Ethiopia is extremely limited. Marie Stopes International, FGAE, Ipas, EngenderHealth and Pathfinder International are integrating HIV into FP services. The Johns Hopkins Bloomberg School of Public Health is conducting a study supported by Packard, Hewlett, and Gates funding, to examine what happens when quality family planning counseling services are introduced into VCT facilities. Starting one year ago, FHI began integrating sexual and reproductive health and gender development including family planning counseling in their home- and community-based care (HCBC) programs as well as in prevention programs, but integration in facility-level services has not started yet. FHI's initiation of SRH/HIV service integration was driven by observations in HIV/AIDS programs of an increased number of female home-based care (HBC) clients becoming pregnant, an increase in People Living with HIV/AIDS (PLHA) becoming sexually active after feeling physically better due to ART, and a clear need for RH/FP services among all HBC beneficiaries including counseling, contraceptives, and STI care.
We first conducted an assessment among HCBC beneficiaries, FHI staff, and NGO partner staff and volunteer care givers to clarify the need for SRH services and/or counseling, and the feasibility of providing these through the existing HCBC structure. During the summer of 2007, we revised our HCBC training curriculum to include sexual and reproductive health counseling, promotion of family planning, support for establishment of community savings groups, and promotion of related positive behavior change using community capacity enhancement through community conversation. The revised HCBC training manual was then reviewed by the different FHI/Ethiopia technical teams, by partners, and by an external SRH/Gender development expert. We then developed indicators to monitor the implementation of the SRH/HIV integration activities and incorporated these in the existing monitoring and evaluation (M&E) system and tools. We are now using the revised HCBC training curriculum to provide refresher training to project level nurse supervisors and to train new groups of volunteer care givers.
Integrated SRH/HIV activities now include family planning counseling as a routine activity conducted by volunteer care givers at the home level, provision of condoms, and referral of the clients to public health facilities to obtain the family planning method of their choice. In the coming year we aim to provide short to medium term family planning methods (pills and injectable contraceptives) through the HCBC programs. Other SRH activities now provided through the HCBC programs include child survival support (e.g. counseling and referral to health facilities for vaccinations, growth monitoring, and Integrated Management of Childhood Illnesses), PMTCT support (counseling, referral to facility-based PMTCT services and home-level follow up of mother and child), promotion of and support for facility-based delivery, and initiation of community-level awareness raising of gender-based violence issues.
What were the dates of the project/program?
We have been supporting the HCBC programs for people bedridden with chronic illness (including due to HIV/AIDS) and their families since 2002/2003. The integration of SRH started in February 2007 and continues.
Who was involved in the discussion and decision-making on the approach to take to address the problem?
- HCBC beneficiaries
- HCBC committee representatives in CBOs involved in the HCBC program implementation
- District health representatives
- Health professionals working in public health facilities to which the HCBC programs refer
- FHI technical, program and management staff
- NGO partner staff (coordinators and nurse supervisors)
- Volunteer care givers engaged in the HCBC service delivery through the CBOs
- Local government administration representatives (kebele, women's affairs and police)
Did you involve the community in developing the program?
Yes, through sensitization meetings, consultations, and ongoing communication activities. Also, Idirs (traditional funeral societies) are a major partner in the implementation of the HCBC programs: they recruit and support volunteer care givers, mobilize support for beneficiaries within their communities, and carry out behavior change communication activities in line with the program's efforts.
How did you work with the District Health Office in setting up the program; for example, in strengthening the systems and services?
The District Health Offices assisted in establishing the referral system between the HCBC programs and the public health facilities to ensure provision of SRH services to HCBC clients. They also directly provide complementary support to the programs, including funding for nutritional support, drugs and other medical supplies. Health professionals working in public health facilities under the District Health Offices, provided SRH training to volunteer care givers and supervision support to these care givers during their practical training. Staff of the District Health Offices are also routinely engaged in HCBC program monitoring activities.
Are there links to community support groups?
Part of the HCBC program activities is to facilitate the establishment of support groups among their clients, family members of clients, and supporting neighbors. Currently more than 100 support groups are involved in the program. Support for SRH counseling, including peer-to-peer FP counseling, has recently started within the support groups engaged in the HCBC programs.
How do the providers and clients feel about the integrated activity?
The following is a quote from a health professional engaged in the program: "Integration of SRH in the HCBC program activities is really very important for the women we serve; however there is resistance from their male partners. This is a great concern for us."
Female clients show great interest in the SRH activities now provided.
Male clients resist the SRH activities, saying that they desire to have children and do not want their female partner to take contraceptives.
What obstacles did you encounter from a program standpoint and how did you address them?
We did not have enough funding to provide contraceptives at home level. This will probably be addressed in the near future. The HCBC programs are very large programs, and it takes time to initiate change in such large structures involving so many partners. This was not an obstacle but the SRH integration took longer than we would have liked.
SRH counseling involves addressing sensitive issues around sexuality and gender which are often very difficult issues to address by the volunteer care givers (cultural norms and practices). This requires specific attention. Also, as cultural norms and practices may inhibit positive SRH change, volunteer care givers can only go so far in their inter-personal counseling efforts. There is a need for a broader behavior change communication campaign to create an enabling environment for behavior change within society.
Did you make adjustments to your approach as you went along? Please describe.
We continuously refined the approach based on feedback from implementation and monitoring findings.
Did you have need for special resources to implement your approach (e.g., funding, staffing, supplies, consultants)?
We engaged an external SRH/Gender specialist to help the FHI team identify how we could integrate SRH and gender in our work. We also engaged a consultant to revise the HCBC curriculum based on our recommendations. Creating the rest of the special resources mainly involved staff and partner time. We are currently leveraging additional funding to provide contraceptives at home level.
Were there systems you developed to manage integrated services, such as client follow-up or special complicated cases?
We adapted existing systems for M&E, follow up, supervision, and referral to also address integrated SRH activities.
Was there training needed in order to be able to offer integrated services?
Yes. To date 108 HCBC nurses and coordinators were trained in the integrated SRH/HIV approach, and 2,200 volunteer care givers.
How did you evaluate the success of your activity?
It is too early to evaluate the success of the SRH integration. We will do this in the coming year.
For more information:
Please contact Family Health International: www.fhi.org
Contact Information
Francesca Stuer,
fstuer@fhi.org.et
Medhanit Wube
mwube@fhi.org.et
Tamrat Assefa
tassefa@fhi.org.et
Phone number:
+251-11-663 98 80