Integrating reproductive health: myth and ideology

Since 1994, integrating human immunodeficiency virus/sexually transmitted d isease (HIV/STD) services with primary health care, as part of reproductive health, has been advocated to address two major public health problems: to control the spread of HIV; and to improve women's reproductive health. How ever, integration is unlikely to succeed because primary health care and th e political context within which this approach is taking place are unsuited to the task. In this paper, a historical comparison is made between the he alth systems of Ghana, Kenya and Zambia and that of South Africa, to examin e progress on integration of HIV/STD services since 1994. Our findings indicate that primary health care in Ghana, Kenya and Zambia h as been used mainly by women and children and that integration has meant ad ding new activities to these services. For the vertical programmes which su pport these services, integration implies enhanced collaboration rather tha n merged responsibility. This compromise between comprehensive rhetoric and selective reality has resulted in little change to existing structures and processes; problems with integration have been exacerbated by the activiti es of external donors. By comparison, in South Africa integration has been achieved through political commitment to primary health care rather than ex panding vertical programmes (top-down management systems). The rhetoric of integration has been widely used in reproductive health des pite lack of evidence for its feasibility, as a result of the convergence o f four agendas: improving family planning quality; the need to improve wome n's health; the rapid spread of HIV; and conceptual shifts in primary healt h care. international reproductive health actors, however, have taken littl e account of political, financial and managerial constraints to implementat ion in low-income countries.