Responding to clients' needs and appeals from women's advocates, health
providers are searching for ways to integrate care for sexually transmitted diseases
(STDs) with family planning programs.
An important question in integrating STD care is how much new services will cost.
Conducting cost analyses can guide policy and provide details for program budgets.
The 1994 International Conference on Population and Development in Cairo called for a
comprehensive approach to reproductive health, rather than a narrow focus on family
planning. Preventing and treating STDs is considered crucial to this approach because some
STDs enhance transmission of the deadly virus that causes AIDS, a major health concern
worldwide.
More than 330 million new cases of curable STDs develop every year and, besides
increasing HIV transmission, they cause pain and infertility in both sexes. However, women
are biologically more susceptible to STD infection, less likely to show symptoms and
harder to diagnose. Women also face harsh consequences, including pelvic inflammatory
disease (PID), cervical cancer and death. STD-infected pregnant women risk ectopic
pregnancy, miscarriage, premature delivery and stillbirth, and their infants may develop
pneumonia or blindness, or they may die. All of these risks are costly to individuals and
to society in terms of medical expenses and lost productivity.
STDs already influence family planning services. A woman infected with or at risk of an
STD should not use an IUD, for example. Barrier methods -- especially condoms -- are a
more appropriate recommendation, since they can protect against STDs, or clients at risk
may wish to combine condom use with another contraceptive. In addition, some women
incorrectly interpret reproductive tract infections as a side effect of their
contraceptive method, says Dr. John Townsend, a Population Council senior associate in
India. Integrating STD care with family planning may mean better care for clients, longer
contraceptive continuation, and higher savings for family planning programs because of
fewer unnecessary visits, he says.
On a policy level, cost analysis can point out the relative costs and benefits of STD
services and indicate how they should be funded. While treating STDs can save money in the
long-term, the cost of maintaining laboratories, training staff and supplying drugs can
burden health budgets that may already be overextended. For example, an FHI study by the
AIDS Control and Prevention (AIDSCAP) Project in five Bangkok clinics found that offering
STD services cost an average of U.S. $19 to U.S. $25 per patient, while the Thai
government was spending only U.S. $20 per capita on all health needs at the time.1
But policy-makers also must be aware of benefits, even those that cannot be quantified,
says Steven Forsythe, health economics officer at AIDSCAP. "If you are doing a cost
analysis, you should make sure that you not only emphasize costs, but the benefits being
achieved," which include lower long-term medical costs, increased productivity,
savings to employers and a reduction in pain, suffering, infertility and mortality for
individuals, he says. These benefits often do not show up on a family planning program's
balance sheet but should be considered at policy levels, experts say.
"Of various [health] investment options, reproductive health interventions rank
among the 'best buys' available," according to Iain Aitken and Laura Reichenbach of
the Harvard University School of Public Health, who studied programs in Africa and Asia.2 And STD treatment ranks as one of the least expensive of these
reproductive health options, per year of healthy life saved.
An FHI report concludes that many international organizations consider STD care an
essential component of a comprehensive reproductive health program, but they disagree
about which services to offer. The study urges policy-makers to plan comprehensive
reproductive health programs methodically, by identifying national health goals first,
followed by making decisions on which new reproductive health services are needed to
achieve the goals. Next, countries should examine funding requirements and sources of
funding, followed by a strategy for implementing new services.3
Cost-effective services
For programs, cost analysis can be used to decide whether STD services fit into the
budget, which of several interventions will be most cost-effective, and how to make
services sustainable. "Sustainability should be built into project planning from the
very start," Forsythe says. "Planners should identify ways of sustaining
services, and not wait until after funding has disappeared." In the course of
analyzing costs, keeping a focus on clients' needs and quality of services is important,
experts agree.
Integrating STD care with family planning can make services more accessible, reach a
network of sexually active women and reduce costs. For example, a study by the Population
Council in Mombasa, Kenya clinics run by the Mkomani Clinic Society found that offering
STD services to a symptomatic client who requested oral contraceptives during the same
visit cost about U.S. $8.60, while offering the services separately cost U.S. $12.40. The
difference, which did not include startup expenses for integration, was due primarily to
savings in overhead and staff costs.4
Deciding which services are most cost-effective is essential. The best approaches for
evaluating cost-effectiveness take into account local STD prevalence, cultural setting and
clients' needs, in addition to available resources. The most appropriate and
cost-effective approach for some family planning programs may be referring clients at risk
to STD clinics. Another simple, often less expensive route to addressing STDs is
prevention -- education and condom distribution -- which has been widely used for HIV
control. Still other clinics are moving to evaluate, diagnose and treat clients, and even
notify their partners.
However, only a few detailed studies have examined costs to determine which of such
interventions would be the most cost-effective -- solving a given problem using the least
amount of money.
In the United States, chlamydial infection is the most common bacterial STD, with about
4 million new cases each year. As with many other STDs in women, chlamydial infection is
often asymptomatic -- most infected women show no signs of having it. However, the
infection can lead to PID, infertility or other serious sequelae, so family planning
clinics have been searching for an effective way to screen and treat women for it.
In one study conducted in the Pacific Northwest region of the United States,
researchers wanted to find out whether selective or universal screening for chlamydia
would be more cost-effective. They evaluated more than 11,000 family planning clients and
19,000 STD clients with a pelvic exam, and asked questions about age and sexual history.
Then they tested all clients for Chlamydia trachomatis using a direct fluorescent antibody
test, an enzyme immunoassay, a DNA probe or cell culture.5
About 6 percent of the women tested positive for chlamydia, and those younger than 20
were most likely to be infected. When medical costs and lost productivity were taken into
account, the researchers concluded that screening all family planning clients for
chlamydia would be more cost-effective than selective screening, if disease prevalence was
above 3 percent. For STD clients, selective screening would be most cost-effective until
prevalence reached 7 percent, because the screening criteria better predicted which of
these women were infected.
An earlier study in California family planning clinics found that universal screening
for chlamydial infection would pay for itself through long-term medical savings if the
prevalence of infection was as low as 2 percent.6
However, these results from the United States cannot be used to predict conditions in
developing countries. Costs vary widely based on several factors, including location,
disease prevalence and type, and the intervention being tested. For example, in the
developing world, syndromic management of STDs, rather than laboratory tests, might be
considered for symptomatic women because of its lower costs. Rent, salaries, drug costs
and other expenses also vary widely.
Few studies in developing countries examine the costs of alternative strategies to
determine which women to treat. In one of the first such studies, Laurie Fox and Alan
Spruyt of FHI collaborated with Jamaican researchers to examine the cost-effectiveness of
STD interventions in two family planning clinics in Kingston, Jamaica. Their study also
estimated the prevalence of chlamydial infections, gonorrhea, syphilis and trichomoniasis
and identified STD risk factors among the clinic's clients.7
The researchers examined a variety of diagnostic approaches to see which was most
cost-effective and worked best to identify and treat clients with STDs. All clients in the
study were interviewed and received a leukocyte esterase urine test also known as urine
LED, which is done with an inexpensive dipstick; pelvic exams; and laboratory tests. The
interview covered a woman's age, her sexual history and symptoms, and those of her
partner. Costs of labor, materials and drugs associated with each screening method were
calculated, but cost of training and equipment were not included.
The relative cost-effectiveness of each strategy was evaluated by comparing these costs
per infection identified and treated. The study's findings were analyzed to determine
which intervention or combination of interventions would be most appropriate in these
clinics.
Of 767 family planning clients screened, 26 percent had at least one STD, and 14
percent of the 767 clients had a cervical infection with gonorrhea or chlamydia. The
interview and urine test together identified more than three quarters of the women with a
cervical infection. Adding a pelvic exam without a laboratory test only diagnosed an
additional 4 percent of infected women, suggested unnecessary treatment for an additional
5 percent of uninfected women and was substantially more costly, adding 38 percent (U.S.
$15) to the cost of each STD identified and treated.
"The interview and urine test do not identify everyone with infections -- we wish
they did," Fox says. "But they are more within the reach of family planning
programs around the world than pelvic exams, which have high costs for training and
equipment, without adding substantially to correct STD identification," she says. All
strategies except the laboratory-based diagnosis missed a sizable number of infected women
and incorrectly diagnosed many who were not infected. The researchers recommended
education and condom promotion at a minimum, and less costly strategies based on methods
such as risk assessment and urine LED as the best current options for STD management among
family planning clients in resource-poor settings.
Integration in India, Colombia
Like Jamaica, India has a high rate of reproductive tract infections (RTIs), which may
afflict up to 60 percent of women. RTIs can result from STDs, overgrowth of normal
microbes in the reproductive tract, or poor clinical practice during IUD insertion, pelvic
exams and other procedures. The Indian government has developed a plan for integrating STD
care with family planning and other health services, and policy-makers are exploring the
best way to proceed.
As part of this preparation, the U.S.-based Population Council is working with the
state of Uttar Pradesh in India to determine the feasibility, strategy and cost of
offering RTI care with other health services.8 The research
team trained doctors in RTI case management, and lab technicians to do simple diagnostic
tests at several health centers with limited lab facilities. They then determined the
costs of training, salaries and services and modeled the RTI program's cost at different
levels of disease prevalence and service use.
Their analysis determined that, at the primary health center level, the program would
cost more than U.S. $2,500 annually to serve 600 people, considered a low level of use.
The drug budget alone would need to double in order to offer services to symptomatic women
-- a small percentage of those who have STDs.
Asymptomatic women were not included in the estimates because the program is just
beginning, says Dr. Saumya RamaRao, the study's lead author. "This is the first
step," she says. "As we get more clients and determine the patterns of
infection, we will know more about how to modify the model and the services."
Because of the high cost of diagnosis and treatment, the Population Council recommended
supporting education efforts, training providers to manage RTI cases, cutting down on
procedure-related infection and encouraging clients' use of barrier methods to reduce
infections.
PROFAMILIA, a family planning organization in Colombia, is among programs that have
already expanded STD services into family planning clinics. Dr. Gabriel Ojeda of
PROFAMILIA cautions that it is essential to budget for all costs -- both fixed ones, such
as equipment facilities and other items, and variable costs, including drugs and other
supplies that change with the number of clients. Salaries, utilities and other costs must
all be taken into account as well.
PROFAMILIA offers STD services at its three types of clinics -- for men, women and
adolescents. Women are not screened for STDs, but those who have symptoms are diagnosed
and treated. Finding out how to pay for such services has been an important consideration,
Dr. Ojeda says. "We have to be financially self-sufficient," he says.
PROFAMILIA's clinics require clients to pay a fee for STD services.
Other programs have asked clients to pay a small amount for STD care. For example, the
AIDSCAP study in Bangkok found that adding night hours drew more STD clients, but the
greater expense of running the clinic at night could not be sustained without more
funding. The study recommended that clients be charged a small fee for exams to help
recoup some costs.
The difficulty, experts say, is that some clients will not seek STD treatment,
contributing to a severe public health problem. So programs have to find a balance.
"We have found that we can offer STD services and people accept them," Dr. Ojeda
says. "There is a demand. If the services are good, people prefer to pay rather than
to go to free government services where the quality is not as high."
Besides charging fees, PROFAMILIA has found that its STD services can remain
financially self-supporting through other means. The organization has arranged contracts
with private medical organizations and with the Colombian social security system to offer
STD treatment and diagnosis as part of a reproductive healthcare package, Dr. Ojeda says.
However, these contracts do not cover costly HIV treatment, which PROFAMILIA cannot afford
to provide, he says. PROFAMILIA also raised funds for its initial integration of STD
services through donations from international organizations.
Family planning managers can use cost analyses to determine how to budget for
integrated care, which services to offer, and how to make them sustainable, experts say.
After evaluating local STD prevalence and type, clients' needs, available resources and
whether STD and other services can effectively be provided elsewhere, those deciding
whether to integrate services should consider a strategy of first starting on a small
scale.
"Program managers need to look at STD prevalence, methods of diagnosis and
treatment, and appropriate means of education and prevention to determine what best suits
the environment in terms of cost and culture," says Fox of FHI. Beginning with a
small pilot program can help clarify how some of these factors work in practice, allowing
managers to adjust their strategy as services expand.
-- Carol Lynn Blaney
References
- Forsythe S, Mangkalopakorn C, Chitwarakorn A, et al.
Opportunities for cost recovery at the female STD clinic in Bangkok, Thailand. Newsletter
for the Thai Medical Society for the Study of Sexually Transmitted Diseases. August
1995.
- Aitken I, Reichenbach L. Reproductive and sexual health
services: expanding access and enhancing quality. In: Sen G, Germain A, Chen LC, eds. Population
Policies Reconsidered: Health, Empowerment, and Rights. (Boston: Harvard University,
Harvard Center for Population and Development Studies, 1994) 177-92.
- Hardee K, Yount KM. From Rhetoric to Reality:
Delivering Reproductive Health Promises through Integrated Services. Research Triangle
Park, NC: Family Health International, 1995.
- Twahir A, Maggwa BN, Askew I. Integration of STI and
HIV/AIDS Services with MCH-FP Services: A Case Study of the Mkomani Clinic Society in
Mombasa, Kenya. Operations Research and Technical Assistance, Africa Project II. New
York: The Population Council, 1996.
- Marrazzo JM, Celum CL, Hillis SD, et al. Performance and
cost-effectiveness of selective screening criteria for Chlamydia trachomatis infection
in women: implications for a national chlamydia control strategy. Sex Transm Dis
1997;24(3):131-41.
- Trachtenberg AI, Washington AE, Halldorson S. A
cost-based decision analysis for chlamydia screening in California family planning
clinics. Obstet Gynecol 1988;71(1):101-08.
- Behets FMT, Ward E, Fox L, et al. Sexually transmitted
diseases are common in women attending Jamaican family planning clinics and appropriate
detection tools are lacking. Genito Urinary Medicine, in press.
- RamaRao S, Townsend JW, Khan ME. A Model of Costs of
RTI Case Management Services in Uttar Pradesh. Operations Research and Technical
Assistance Project, Asia and Near East. New Delhi: The Population Council, 1996.
For more information, visit Family Health International's Website at www.fhi.org
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