Integration of STI services into FP/MCH services: health service and social contexts in rural Ghana.

Ghana, like many countries, has taken up the call to integrate STI management with MCH/FP services. Since 1994 a range of policies has been developed on safe motherhood and family planning, as well as syndromic STI management guidelines for 'mid-level' staff and an all-encompassing 'reproductive health' policy. The success of these policy initiatives depends to a large extent on the processes and contexts of implementation, yet analysis of this has rarely been undertaken. This paper analyses the rural context of policy implementation in the rural Upper East Region of northern Ghana and suggests that a 'blanket' policy to integrate STI and FP/MCH services may be inappropriate in particular contexts. It illustrates how the implementation of health policies is influenced--and often impeded--not only by local service contexts, economic and epidemiological factors but also by culturally defined social attitudes and behaviours. These can influence not only whether a policy is accepted by a population but also how it is implemented by health staff. Future reproductive health policy needs to address these issues in order to develop goals which can realistically be implemented in specific settings. Enhancing at district level the voice of nurses working at community level and promoting collaborative, culturally-specific and community-based initiatives could facilitate this.