Options And Challenges For Converging HIV And SRH Services .
Options and Challenges for ConvergingHIV and Sexual and Reproductive HealthServices in IndiaFindings from an Assessment in Andhra Pradesh, Bihar,Maharashtra, and Uttar PradeshJune 2007
PATH is an international, nonprofit organisation thatcreates sustainable, culturally relevant solutions, enablingcommunities worldwide to break longstanding cycles ofpoor health. By collaborating with diverse public- andprivate-sector partners, we help provide appropriatehealth technologies and vital strategies that change theway people think and act.Headquartered in Seattle, Washington, PATH operates 27offices in 18 countries. The India country office is based inNew Delhi, with project offices in Lucknow, Mumbai, Hyderabad, and Imphal, as well as partnership operations inAssam, West Bengal, Bihar, Tamil Nadu, and Karnataka.This assessment was carried out by PATH with financial supportfrom the William and Flora Hewlett Foundation, the David andLucile Packard Foundation in India, and from the Department forInternational Development (United Kingdom). The views in thisreport do not necessarily reflect the views of these organizations.Copyright 2007, Program for Appropriate Technology in Health(PATH). All rights reserved. The material in this document may befreely used for educational or noncommercial purposes, providedthat the material is accompanied by an acknowledgement line.For more information, please contact:Dr. Amitrajit SahaAssociate Director, Sexual and Reproductive Health, IndiaPATHTel: 91-11-26530080 to 88Fax: 91-11-26530089Email: asaha@path.orgwww.path.orgCover photo: Siri Wood2
AcknowledgmentsThis assessment was carried out by PATH with financial support from the William and Flora Hewlett Foundation,the David and Lucile Packard Foundation in India, and from the Department for International Development (UnitedKingdom). The assessment team was comprised of Amitrajit Saha, Tilly Sellers, Madhavi Panda, Raj Kumar Bidla, andIrfan Khan of PATH. Jeff O’Malley, PATH’s Country Director for India Program, provided guidance to the project,Patricia Coffey provided technical support from Seattle and Smriti Acharya, Samuel Varaprasad, Swati Pongrulekar,Omega Jyotsna and Indira Rani from PATH provided assistance at state level.First, we would like to thank senior government officials from the departments (and bureaus) of health and familywelfare, the state health societies, and the state AIDS control societies of Andhra Pradesh, Bihar, Maharashtra, andUttar Pradesh:Andhra PradeshC. B. S. Venkata Ramna (former Commissioner, FamilyWelfare, Government of Andhra Pradesh); G. AshokKumar Pillai (Project Director, Andhra Pradesh StateAIDS Control Society); Dr. P. Venkateswara Rao(Director, Family Welfare, Government of AndhraPradesh).BiharDeepak Kumar (Principal Secretary/Commissioner,Department of Health and Family Welfare, Governmentof Bihar); A. N. Singh (former Project Director, BiharState AIDS Control Society); Jayant Kaushal (RegionalDirector—Bihar and Jharkhand, Department of Healthand Family Welfare, Government of India).MaharashtraAnna Dani (Principal Secretary, Family Welfare,Government of Maharashtra); Dr. P. P. Doke (DirectorGeneral, Health Services, Government of Maharashtra);Dr. Chitale (Joint Director, Reproductive and ChildHealth, Government of Maharashtra).Uttar PradeshDr. Shakeel Nayara (Joint Director, Reproductive andChild Health, Government of Uttar Pradesh); Dr. S. P.Goel (Project Director, Uttar Pradesh State AIDS ControlSociety); Dr. Aradhana Johri (former World HealthOrganization advisor on polio, now Joint Secretary,Ministry of Health and Family Welfare, Governmentof India).We would also like to acknowledge the contributions of the local advisory groups:LucknowDr. K. K. Singh (Chief Medical Officer of Health); Dr.C. B. M. Tripathi (Director, Maternal and Child Health,Government of Uttar Pradesh); Dr. Rajiv Chowdhary(Assistant Director, Uttar Pradesh State AIDS ControlSociety); Dr. Neelam Singh (Vatsalya); Sehba Hussain(Better Education Through Innovation) ; Kaushik Das(Naz Foundation International); Bharat Bhushan(People’s Action for National Integration); Qasim Mehndi(Bharosa Trust).PatnaDr. Geetanjali Kumari (former Assistant Project Director,Bihar State AIDS Control Society, now RegionalCoordinator, East, National AIDS Control Organisation);Sanjay Kumar Sinha (Assistant Director – Condompromotion, Bihar State AIDS Control Society); Dr. C.B. Singh (Civil Surgeon cum Chief Medical Officer ofHealth); S.Pankaj (Organisation for Socio-Economic andRural Development); Ram Kishore Prasad Singh and Anju(Gramin Evam Nagar Vikas Parishad); Pawan Kumar;Pinky; Manju; (Suryodaya Sarvagirn Vikas Parishad);Christopher Bachman (YMCA, Bihar); Rajneesh Singh(President, The Bihar Network For People Living WithHIV/AIDS).SrikakulamDr. M. V. Ramanna Rao (Joint Director, Andhra PradeshState AIDS Control Society); Dr. Jaganmohan Rao(former District Medical and Health Officer); KanakaDurga (District Project Officer, Integrated ChildDevelopment Service); Dr. P. Tirupathi Rao (DistrictTuberculosis Control Officer); Dr. B. Rama Rao (ProjectOfficer); Dr. G. Kondala Rao (Field Publicity Officer); S.Raveendar (Resource Education Society); M. Prasad Rao(Youth Club of Bejjipuram); Sarojini; Ramanna Amma;Padma.3
NashikDr. A. B. Chitale (former Joint Director, Maharashtra StateAIDS Control Society, now Joint Director, Reproductiveand Child Health); Dr. P. D. Gandal (AssistantDistrict Health Officer); Dr. P.H. Aher (District TBofficer);Kshirsagar Arvind (Manas Vyasanmukti Kendra);Kailash More (Lokvikas Samajik Sanstha); PrakashYende (President, Positive People of Amannagar); Dr. C.R. Namapurkar (Project Manager, Manas VyasanmuktiKendra); Kavita Shivdas Shikhare (Krupa Prasad Careand Support Centre) (now deceased); Neelesh Sonawane(Krupa Prasad Care and Support Centre).The assessment team would like to acknowledge thecontributions of staff from Research Pacific International:James Washington, Archana Sinha, Tilak Arora, PriyaPanwar, and Shruti Singh.Our thanks also go to the community investigators:G. Sarojini; B. Sarojini; Ramalaxmi; Indira; G. Srinu;G. Raju; Prashant; Gautam (National Key PopulationConsultant [NKPC]); Priya Murthy (NKPC); Anita;Sanjita; Meena Devi; Kailash Bhagat (now deceased);Mahua; Asha Bhatia; Moin (NKPC); Munnisa (NKPC);Sangeeta (NKPC); Gayatri (now deceased); Bhoju Singh;Jyoti Pawar; Manisha; Madhuri; Kshama; Savita; Sunita(NKPC); Tanaji (NKPC); Ranno; Manju Pandey; NeelamRawat; Kavita Rawat; Gopal Gour; Indira; Laxmi; Srinu(NKPC); Vijay (NKPC); Prashant; Vijay; and Suresh.We would like to acknowledge the administrative supportreceived throughout the assessment from SrinivasanVenkatraman and Aditi Joshi of PATH. Finally, we wouldlike to express our gratitude to all those who participatedin the assessment and shared their time and thoughts tohelp us understand the issues.AcronymsAIDSANCANMARTBCCCBOCHCDOTSAcquired immune deficiency syndromeAntenatal careAuxiliary nurse midwifeAntiretroviral therapyBehaviour change communicationCommunity-based organisationCommunity health centreDirectly observed (tuberculosis) treatment shortcourseHIVHuman immunodeficiency virusHSPC Human Subjects Protection CommitteeICDSIntegrated Child Development ServiceICTCIntegrated counselling and testing centreIECInformation, education, and communicationLAGLocal advisory groupLTFQP Less than fully qualified practitionerMCH Maternal and child healthNACO National AIDS Control OrganisationNACP National AIDS Control SSRHSTDSTITBVCTWHONongovernmental organisationNational Rural Health MissionProgram for Appropriate Technology in HealthPrimary health centrePrevention of mother-to-child transmissionPrevention of parent-to-child transmissionReproductive and child healthReproductive and Child Health ProgrammeRegistered medical practitionerReproductive tract infectionState AIDS control society/societiesSexual and reproductive healthSexually transmitted diseaseSexually transmitted infectionTuberculosisVoluntary counselling and testingWorld Health Organization
Table of contentsAcknowledgments .Acronyms .Executive summary.Summary of findings from participatory mapping .Summary of findings from interviews with service providers .Summary of findings from interviews with policymakers .Conclusions .Introduction .What is convergence .Directions of convergence .Benefits of convergence .Challenges of convergence.Populations of interest for convergence .Convergence needs in India .Government services and convergence policy in India .Assessment of HIV-SRH convergence in four states .Assessment objectives and questions .Assessment methods .Selection of assessment sites .Forming local advisory groups .Selection and training of the assessment team .Developing and pre-testing data collection instruments .Selection of assessment participants and data collection .Findings from participatory mapping .Managing sexual and reproductive health .HIV and SRH service and information needs .Barriers to service use .Demand for convergence .Findings from interviews with service providers .General attitudes toward convergence .Benefits of convergence .Challenges in implementing convergence.Training needs.Policy and partnerships .Findings from interviews with policymakers and influencers .Policy and partnerships .Funding and cost implications .Provider skills .Conclusions .Limitations of the assessment.Implications for implementing and scaling up HIV-SRH service convergence.Implications for strengthening capacity for convergence.Implications for translating policy into practice .Further research 832333334373941414242434344454646Annexes .Annex 1. Sexual and reproductive health services provided in the public sector in India .Annex 2. Current policy regarding integration of HIV and SRH services in India.Annex 3. Resource materials developed by PATH for the convergence project .Annex 4. Background information on assessment districts .Annex 5. Terms of reference for local advisory groups.Annex 6. Participatory mapping guidelines .Annex 7. Guidelines for semi-structured interviews with service providers and policymakers .Annex 8. Consent form.Annex 9. Suggested convergence options .References .48484950515759616366695
Community investigators learn how toconduct participatory mapping. PATH—Hyderabad, India, June 2006.PATH6
Executive SummaryThis report is primarily for state- and district-level policymakers and service providers working in the government and innongovernmental organisations (NGOs) in India. The report aims to share findings from an assessment carried out byPATH to explore how access to critical services for populations at risk of HIV and unintended pregnancy can bestrengthened by converging HIV and sexual and reproductive health (SRH) services under the National Rural HealthMission (NRHM) and the National Aids Control Programme (NACP). The report provides information on the demand andopportunities for and the challenges of implementing HIV and SRH convergence in four states—Andhra Pradesh, Bihar,Maharashtra, and Uttar Pradesh.Global evidence shows that populations at risk of HIVand unintended pregnancies, such as young men andwomen, people who sell sex, and people with HIV,are not able to access the HIV and SRH services theyneed. Young women and sex workers, for example, havedifficulty accessing family planning services, which aregeared toward the needs of married women. Servicesfor family planning, maternal and child health (MCH),sexually transmitted infection (STI), HIV, and abortionare provided separately and often target differentpopulations. Consequently, there are several missedopportunities for providing a better response to HIV andSRH. “Convergence” of HIV and SRH services refers toa very wide range of activities or processes, which areundertaken with the broad objective of capturing these“missed opportunities” by adding on services or payingattention to the overlap areas in HIV and SRH.The Government of India has recognised the need forconverging or linking HIV and SRH services in theReproductive and Child Health Programme (RCH II),the National AIDS Control Programme launched in2007 (NACP III), and in the NRHM. Whilst the policyenvironment is favourable, the voice of the client, ordemand for different convergence options, is significantlylacking, and state governments lack the evidencenecessary to make informed decisions about what optionswill work best in different settings. In recognition of thisneed, PATH worked with state governments, NGOs,and local communities in Bihar, Andhra Pradesh,Maharashtra, and Uttar Pradesh to identify the optionsfor and challenges of HIV-SRH convergence.An assessment was conducted in one district in eachstate in order to generate an understanding of thedemand for HIV-SRH convergence and of the potentialchallenges of responding to this demand. The assessmentwas carried out with HIV and SRH service providersand policymakers and with people at risk of HIV andunintended pregnancy (female sex workers, sexuallyactive young men and women, and people with HIV).Background information and secondary data on theassessment districts were collected first. This wasfollowed by participatory mapping and analysis ofpotential convergence options with 1,545 sex workers,young people, and people living with HIV. Semistructured interviews were then conducted with 159service providers and 60 policymakers to assess theopportunities for and challenges of implementing theconvergence options suggested during mapping activities.The preliminary findings and key convergence optionsthat emerged from the assessment were verified with stateand district stakeholders through a series of meetingsto prioritise convergence options that could potentiallybe taken forward. Local advisory groups in each statewere convened to support the assessment process. Keyquestions for the participatory mapping part of theassessment included:What SRH-related illnesses do groups at risksuffer from?How do they manage these conditions?What are the barriers to accessing HIV and SRHservices?What specific convergence options in each areawould increase access to HIV and/or SR services?During the semi-structured interviews, respondents wereasked about their general reactions to converging HIVand SRH services, what they felt would be the feasibilityof responding to the demand to implement specificconvergence options in their facilities, what would be thetraining needs and policy and cost implications, whatpartners would be needed, what would be the benefitsand barriers, and who would be influential in makingconvergence happen.7
Summary of findings from participatory mappingFindings from the participatory mapping showed thatSTIs are wide
of Bihar); A. N. Singh (former Project Director, Bihar State AIDS Control Society); Jayant Kaushal (Regional Director—Bihar and Jharkhand, Department of Health and Family Welfare, Government of India). Th is assessment was carried out by PATH with fi nancial support from the William and Flora Hewlett Foundation,
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