compatibility among service clusters, availing themselves of possible arrangements for linkage, coordination, or integration. Their decisions can be guided by establishing targeted levels of effectiveness in terms of outreach and coverage and by defining measurable outcomes and developing protocols to guide activities of staff by type of facility.

Hardee and Yount (1995) identify potential linkages among traditional health programs that can strengthen access to reproductive health services. For example, an aim to reduce the level of unsafe abortion could explicitly involve linking family planning and maternity care services with information, education, and communication programs to generate demand for family planning prior to conception. Clients obtaining induced abortions or postabortion care would be provided or referred to family planning services. This linkage would mean coordinating the service provision of the two programs, including defining referral guidelines for abortion clients. Similarly, because STDs increase the probability of a potentially fatal ectopic pregnancy, STD management services could be coordinated with family planning by having former STD clinics automatically provide contraceptive counseling and supplies to male and female clients at risk of unwanted conceptions and having family planning clinics screen for gonococcal and chlamydial cervicitis.

Integration of Services

To what extent services should be integrated is a central issue in reproductive health care (e.g., Hardee and Yount, 1995; Pachauri, 1995). By virtue of its broad definition, reproductive health includes services traditionally offered through a number of categorical programs, particularly those responsible for managing STDs and pregnancy and maternal health problems.

Smith and Bryant (1988) illustrate two types of integration, using malaria and family planning programs as examples (see Figure 6-1). Both kinds of programs have enjoyed a certain degree of autonomy within public health programming, largely due to their access to financial and material resources, some of which has been externally available from international donors. In panel (a), malaria and family planning programs are two of three (with general health services) program blocks; each is administered and implemented somewhat autonomously and has different field staff. In panel (b), the two programs are independently administered at the central level, but their services are delivered in an integrated manner by multipurpose field staff. Reproductive health programs, if organized along highly vertical lines, might resemble one of the columns in panel (a). In the configuration shown in panel (b), in contrast, reproductive health would maintain some separate identity near the central

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