Women Making a Difference

Source: David Alexander, JHU/CCP

Nfila Chalebiwa Chikadze

Community Home-Based Care and Orphan Care
Ministry of Local Government, Botswana

A Successful Integrated Approach to Health Services
Ms. Nfila Chalebiwa Chikadze's background as the District AIDS Coordinator managing HIV/AIDS activities at the national and district levels and her experience practicing as a community health nurse and midwife give her a valuable perspective for managing integrated service delivery.

The Johns Hopkins Bloomberg School of Public Health Center for Communication Programs interviewed Ms. Chikadze about her experience with this integrated approach.

Can you tell me about your position with the Ministry of Local Government?
I work under the Ministry of Local Government. We are mainly dealing with HIV/AIDS coordination as well as primary health care. We oversee all the districts when it comes to coordination of HIV/AIDS as well as implementation of primary health care services.

Do the services include reproductive health?
They include all reproductive, maternal child health, and IEC – Information, Education, and Communication. Maternal child health includes antenatal clinics, child welfare, curative services, and education. IEC is part of it because at the health facilities they even do home visits to different clients. Family planning services are offered with maternal child health.

Are there service delivery guidelines at a national level?
Yes, for family planning, for maternal child, everything, so when you go for a supervisory visit, you are going with those standards and procedures and check whether these things are still being done accordingly. The Ministry of Health is the one which is responsible for policies and procedures because we need uniform policies, so that is not only district X which is doing that; it is everybody that is following the same policies and procedures.

What led the Ministry to begin offering integrated services?
Integrated services were brought in because of a shortage of man power. We found that it wasn't client friendly for one to come for one service and then later come for another service at a certain time. And again, we don't have so many specialized facilities, so it would help both the service provider as well as the people who are receiving the services. You'll find if it's a midwife, she will be doing antenatal care as well as curative because you might be pregnant and not be well, so you need to be consulted. You might have brought your younger child for child welfare, so with integrated services you don't need to go home and come again. After that, you get to another room where your child is given immunizations, and if the child is not well, he/she is also treated; you get your medicine, and you go. Everything is done at the same time.

As a service provider, what was it like to move from a separated, decentralized system to the integrated services?
At first we were thinking, "How will we manage?" But after going through the system, we thought it was going to be very useful because whoever comes in you assist that individual's needs. We had in-service training, so that we could look at the system in a positive manner.

What did the training consist of to enable you to offer additional services?
It was to change the mindset: to say if you have been doing curative from 7:30 to 12 o'clock, then in the afternoon is family planning. Why can't you provide both together? It was to change how we looked at the system, what primary health care consists of, and how we are supposed to integrate services.

So when a patient comes to the clinic, do they see more than one of the nurses for different things, or is it just the one nurse who provides treatment?
Depending on what they came for, you'll find that in the facilities there is a curative side, and there is a maternal child health side. So that at least there will be somebody doing family planning; there will be somebody on the other room doing maybe antenatal clinic; there will be someone doing child welfare – the weighing, the immunizations and giving health talks. All the doors are marked. This door is for curative, this door is for child welfare, so when the clients ask, there is somebody who directs the people to the services they need. Let's say you came for antenatal clinic, and you are not well, and the nurse is a midwife. It means that as a midwife, she has also done general nursing. In our country, we start with general, and then you can have other qualifications. We don't have a nurse that can be a midwife without basic general nursing skills. So even if you are a midwife, you will do the midwifery part, maybe palpation and the like, and thereafter if that mother is not feeling well, we start writing and [state] the treatment. Then she goes and gets the treatment.

So you offer the HIV testing even if somebody came in for family planning, or if they came for antenatal care?
Anything, yes. There's nowhere it will be labeled "HIV Testing." We have a small room where you can be tested for hepatitis B, for other things, and even blood for HIV is taken there, so it's not somewhere where you could be separated to a room only for HIV testing. Even at the consulting room, the nurse can take your blood without people outside knowing that you came in for HIV testing.

If you had to give any sort of advice to another country that was going to be trying to integrate services, what do you think are the most important things for them to know?
First, you will need to understand how they define their services. How many service providers do they have in one facility, against how many people, and then the type of facilities they are in. Then considering that, you can start from there. And the training, I think, is also important because it's not only how many providers are there, the type of training that they have, whether it is a midwife, general nurse-midwife, or it's only a midwife, so that when you now deploy the man power you know what you need in an integrated facility.

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