Nfila Chalebiwa Chikadzi currently serves as a Policy Advisor for the Community Home Based Care (CHBC) and Orphan Care programs run through the Ministry of Local Government in Botswana. She provides technical guidance, direction and support to officers in charge of CHBC and Orphan Care programming at the district level. From 2002 to 2006, Ms. Nfila served as the District AIDS Coordinator where she assisted the District Multi Sectoral AIDS Committee (DMSAC) in the coordination and management of HIV/AIDS activities at the national and district level. Ms. Nfila obtained her nursing degree from the University of Botswana and also holds a diploma in General Nursing , Midwifery and in Community Health Nursing.
The HIV/SRH Integration site interviewed Ms. Nfila about her experience with providing integrated services in Botswana.
Can you tell me about your position with the Ministry of Local Government and what you’ve been doing with HIV services?
I work under the Ministry of Local Government as policy advisor for Home Based Care and Orphan Care . We are mainly dealing with HIV/AIDS coordination, as well as primary health care. What it means is that we are responsible for the overall coordination of HIV/AIDS programmes, and the implementation of primary health care services in all the districts.
What is included with primary health care services?
These are all basic health care services provided at clinics, health posts, and at community level The services should be affordable, accessible, acceptable and easily available. Would they include all reproductive, maternal and child health services and IEC-(Information, Education, and Communication). Reproductive/Maternal child health includes antenatal clinic, child welfare, curative services and education. Health personnel conduct home visits to different clients and go for mobile stops at some hard to reach areas.
Are family planning services also offered?
Yes. They are offered within maternal child health. We use an integrated approach whereby the client is given all services that they have come for. (Its a one stop show.)
When did you begin offering HIV/AIDS services at the clinics? Or in the health care system at all?
Integrated services started, I think, in the early 80s.
What led the Ministry to begin offering integrated services?
Integrated services were introduced after the realization that the initial system was not client friendly, inadequate man power and lack of specialized facilities, so it would help both the service provider as well as the client. You’ll find if it’s a midwife, she will be doing antenatal clinic as well as curative services, because the client might be pregnant and not physically well at the same time, so she may need consultation for her sickness apart from the ante natal services that she came for. That same mother might have brought her younger child for child welfare and the child will be attended as well. If the child is due for the immunization they are given. And drugs are also provided for in the same facility. Everything is done at the same place.
As a service provider, what was it like to move from a separated, decentralized system to the integrated services?
At first we thought we could not manage , but after putting the system into practice, we realized it was helpful because as clients come in they are assisted hence they do not delay or come back another day.
What was the implication for training? Did you get additional training?
Yes, we got in-service training so that we could understand how the system works.
What did the training consist of to enable you to offer additional services?
It was to change the mindset of the health workers for example, doing curative from 7:30 to 12 o’clock, then in the afternoon family planning--why can’t they be provided 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, with the integrated services 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 for antenatal clinic, there will be someone doing child welfare – the weighing, the immunization and giving health talks. And then there will be someone doing other things. 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 nursing, 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 write out the prescription, then she goes and gets the treatment.
Now back to the doors labeled, or the lines labeled; I can see that being a non-issue for curative services and for maternal health, but when it comes to HIV testing, isn’t there going to be some sensitivity about being labeled as getting HIV testing?
No, we don’t label for HIV.
So you offer the HIV testing even if somebody came in for family planning, or if they came for antenatal care?
Yes, routine HIV testing has been introduced nationwide in all health facilities. There’s nowhere where it will be labeled “HIV Testing.” We have a small room where you can be tested for HB, 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, it’s 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. Because otherwise you might think you are giving them two nurses, while you are only giving them general nurses and no midwife. How do you integrate the maternal child health when there is no one who will be doing those things?
What kind of data do you track with these clinics? Do you collect information about how many clients they’re serving, about how many family planning methods are provided?
Yes, in Botswana, every facility has statistics which show how many people have been seen and the type of illnesses. At the end of the month, they compile the statistics and send them to the district, and every district has a team, which is led by the public health specialist. They analyze the data at the district, and then they send the copies to the ministry.
We also do supervisory visits. There are people at the ministry who are responsible for primary healthcare, so they conduct supervisory visits, and go to the districts to see what is happening.
Are there service delivery guidelines at a national level?
Yes. For all services provided. So, when you go for a supervisory visit, you take along 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 standardized policies, so that is not only district X which is doing that, it is everybody that is following the same policies and procedures.
You said that before the beginning of integrated services, people would say, for example, Wednesday is for child care, and then it changed so that people could go for any service, any day, and the Minister made that pronouncement. So was there any type of outreach campaign to let people know that it had changed?
In our facilities, every morning, we do group education, and people would be informed where to get what services. Also people are informed on the radio. If there is any change, you need to make people aware; otherwise they will stay at home and think the system is still the same, so we had to come up with some means of informing people well in advance.
Contact Information:
Nfila Chalebiwa Chikadzi
PO Box 40007
Gaborone, Botswana
Southern Africa
Tel: 3951347
Mobile: (267) 71426742
Fax: 3901976
E-mail: c_nfila@yahoo.com
