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To what extent are maternal and child health, family planning, and nutrition policies supporting integrated service delivery in Burkina Faso, Côte d’Ivoire, and Niger?

Archives of Public Health volume 83, Article number: 101 (2025) Cite this article

Abstract

Background

Service integration is a strategy to reduce maternal and infant mortality rates. “We analyzed the extent to which maternal and child health, family planning, and nutrition policies support the integration of maternal and child health services in Burkina Faso, Côte d’Ivoire, and Niger.

Methods

We performed a document review of policy documents on nutrition, family planning and maternal and child health using the READ approach (Ready materials, Extract data, Analyze data, Distill). We conducted a systematic search for documents among key informants interviewed at the central level and health centers. The Ten Key Principles for Successful Health Systems Integration of Suter’s framework were used for data analysis.

Results

The policy documents adopted a continuum of care approach and focused on mother, newborn, and child health (MNCH); family planning (FP); and nutritional needs throughout the course of life. However, in all three countries, most family planning and nutrition guidelines do not consider globality of care. These documents focus on the main themes of family planning and nutrition. None of the documents analyzed provided clear guidance on how providers should provide integrated MNCH, FP, and nutrition care to mother-child pairs in health centers.

Conclusion

Policy documents serve as practical guides for the provision of care in health centers. It is time to update national policies by including a vision of integrated service delivery for maternal and child health, family planning, and nutritional services.

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Text box 1. Contributions to the literature

• The integration of MNCH/PFPP and nutrition as a recommendation in strategic guidelines and policy documents will facilitate the effective integration of these services in health centres

• FP stakeholders should integrate other themes (MNCH, nutrition) into their policy and strategy documents in the same way that they advocate the integration of FP into other services

• The availability of a guideline for integrating care would help providers offer integrated MNCH/FP/Nutrition services to mother-child pairs in health centers

Background

The maternal and infant mortality rates remain high in resource-limited countries. The causes of these deaths are known and several initiatives and strategies have been implemented in many African countries to reduce mortality [1]. One such strategy is the integration of maternal and child services from pregnancy through delivery, and the postpartum and early childhood periods [2,3,4,5,6].

The need for the integration of care is increasingly affirmed by major actors in international health and policymakers at the country level [4, 5]. According to the World Health Organization (WHO), health policy includes all strategic decisions taken by governments to improve community health. These policies are fundamental in guiding the structure, governance, and performance of health systems [7].

Analysis of these health policies helps understand the functioning of organizational programs and policies in the health system and the efficiency of health systems in making health services accessible to beneficiaries [8]. The findings of these analyses enable learning from past experiences and improving current and future policies [9, 10].

Therefore, several studies have been conducted on health policy analysis in low- and middle-income countries (LMICs) with varying objectives and methodologies (literature review, interviews, and observations). While some authors have focused on policy implementation [11,12,13,14,15,16], others have examined policy formulation [17,18,19,20,21,22,23,24] or both [19, 21, 22, 24, 25]. In an evaluation of the implementation of a policy aimed at improving financial access to maternal health care in Burkina Faso, Belaid and Ridde noted that district officials and health workers had difficulty implementing the policy due to a lack of clarity on some issues in the guidelines [13]. Another study on policy formulation under performance-based financing (PBF) in Tanzania found that the process of implementing PBF was highly political, with strong influence from external actors and less leadership from the government [23].

Some authors have explored policy content and/or formulation [17, 26,27,28]. Place et al. assessed policies related to postnatal depression in Mexico City through a literature review [28]. Asiki et al. showed that although Kenya has a multilevel health system, including primary healthcare (PHC), the integration of cardiovascular disease prevention and control at the PHC level was not explicitly mentioned in policy documents [29]. A multicountry study evaluating the evolution of African Union policies related to maternal and child health found that the priority given to women and children’s health issues is primarily due to human rights considerations [27].

Integrated health services include ‘the management and delivery of health services so that clients receive a continuum of preventive and curative services’ based on needs, over time, and across health system levels [30].

Few authors have addressed the integration of maternal and childcare in policy guidelines [31], and most of them addressed implementation in terms of feasibility, acceptability [32], effectiveness and impact [6, 33, 34]. However, policy guidelines serve as a checklist for providing care at the health-facility level. Policy and strategy documents are the primary tools used to provide a vision and direction for healthcare.

‘The present study aims to assess the extent to which national policy documents and strategic plans support the integration of maternal and child care (MNCH), family planning (FP) and nutrition services” and in order to contribute improving current and future policies. This study is part of a large research project on the integration of maternal and child care, family planning, and nutrition, called INSPiRE (Integration Nutrition, Soins essentiels du nouveau-né et Planification familiale postpartum / santé reproductive), conducted in nine countries of the Ouagadougou partnership. The INSPiRE Initiative, funded by the Bill and Melinda Gate Foundation, aims to reduce maternal and child deaths through service integration. To date, three articles have been published on the study protocol [35], gaps and opportunities for integration in health centers [36], and assessment of the staffing needs of frontline healthcare workers [37]. The present manuscript focuses on the level of integration of policy and strategy documents in Burkina Faso, Cote d’Ivoire, and Niger, chosen from nine countries to implement the pilot phase of the INSPiRE intervention.

Methods

Study setting and design

The study took place in Burkina Faso, Côte d’Ivoire, and Niger, three resource-limited countries located in West African. These countries have similar health systems, with high maternal and infant mortality rates. In 2020, the maternal mortality ratio was 441 in Niger, 264 in Burkina Faso, and 480 in the Côte d’Ivoire [38]. The infant mortality rate was 48 in Niger, 43 in Burkina Faso, and 27 in Côte d’Ivoire [39,40,41] ). The healthcare system is pyramidal, with three levels. The first level included health districts with district hospitals and their networks of primary healthcare facilities. The second (regional) or intermediate level, represented by regional hospital centers and maternal and child health centers (Niger), are the reference points for district hospitals. The third level, comprising national or university hospitals, has the highest reference level in the healthcare system.

Needs assessment showed a low level of integration of maternal and child services in health centers in the three countries.

We conducted a qualitative study focusing on reviewing policy documents following the READ approach (ready materials, extract data, analyze data, and distil) from June to July 2018. The READ approach is a systematic process for collecting documents and extracting information from them in the context of health policy studies at any level (global, national, local, etc.). The steps consist of (1) preparing the materials, (2) extracting data, (3) analyzing data, and (4) distilling the results [45]. We interviewed healthcare providers and programme managers at the central level.

Data collection

We collected data from national policy and strategy documents of the three countries.

Selection and inclusion of policy documents

In all three countries, official policy and strategy documents are available in hard copies. This led us to conduct a systematic search for these documents among key informants interviewed at the central level and in health centers. Documents were identified from the official websites of the Ministries of Health in the three countries. They were supplemented and confirmed during interviews with key informants. Documents were collected from sources such as government ministries, international organizations, and mother-and-child program managers in each country. We selected documents by applying the following two criteria:

  • The main theme addressed in the document is that it should focus on at least one of the following themes: Maternal and Neonatal Health, Family Planning, Nutrition.

  • The period covered by the document: the document identified should be up to date.

any document addressing FP, nutrition, or maternal and child health which is not up to date during data collection in 2018 was excluded from the study.

Data extraction

We developed focused extraction templates to guide the review of selected policy and strategy documents, and extracted data for analysis. Data were extracted into a template developed in Microsoft Excel that recorded information on specific aspects of FP, nutrition, maternal and child health policies, and programs. All the selected documents were read, and the data were extracted by focusing on the type, objectives, activities, and components of the document.

Data analysis

The extracted data were coded and examined to check for coherence and to eliminate duplicates. We used the Ten Key Principles for the successful integration of health systems proposed by Suter [46]. To assess the globality of the care and care continuum in policy documents, our analysis focused on three of the ten elements of Suter’s framework: Comprehensive Services across the Care Continuum, Patient Focus, and Standardised Care Delivery [46]. Comprehensive Services across the Care Continuum include the continuity of care. We analyzed the continuity of care by considering the life course of the mother and child.

Patient focus considers the needs of the patient as a whole. This represents a globality of care. According to Rogers and Sheaff, the justification for integrated delivery systems is to meet patient needs [47]. At this level, we looked for more than one theme to consider in the same document.

In practice, the links between the guidelines on MNCH, FP and Nutrition are understood as being the inclusion in a document focused on a given theme (MNCH, for example) of elements (objectives, components, or activities) on other themes (nutrition, FP).

We also analyze whether the document defined standardized care delivered by interprofessional teams.

Results

Review of policy and strategic orientations in MNCH, FP and nutrition in the three countries

According to the selection criteria defined in our study, 28 policy and strategy documents on MNCH, FP, and nutrition were selected, including 9 in Burkina Faso [45,46,47,48,49,50,51,52,53], 10 in Côte d’Ivoire [54,55,56,57,58,59,60,61,62,63] and 9 in Niger [64,65,66,67,68,69,70,71,72](Table 1).

Table 1 Policy and strategy documents analyzed in the three countries
Full size table

Comprehensive services across the care continuum

The level of integration of services in policy and strategic documents is high in almost all documents analyzed in Niger (8/9) and Côte d’Ivoire (8/10). These documents have a continuum of care approaches and target MNCH, FP, and nutritional needs throughout their life cycles. For example, in the National Maternal, Newborn, and Child Health Strategic Plan 2016–2020 of Côte d’Ivoire, integration is affirmed in the following statement:

“In line with the PNDS, the maternal and child health strategic plan will focus on improving maternal health through safe motherhood by implementing key interventions to: i) make available integrated maternal health care services, ii) promote family planning iii) ….” RMNCIAH 2016–2020, Côte d’Ivoire.

Nutritional guidelines also call for integrated care approaches. The 2017 National Nutrition Guidelines make this clear in Guideline 14 on monitoring the nutritional status of newborns:

“Assess nutritional status up to 6 months postpartum; This assessment is done at each contact with the health facilitysuch as growth monitoring, vaccinations, medical consultations (mother and/or child) " National Nutrition Guidelines 2017, Côte d’Ivoire.

In Niger, the Action Plan 2012–2020 recommends ‘integrating FP into the minimum activity package for health centers' as a high-impact activity.

In addition, it aims to achieve a specific objective. Several priority actions have been selected to promote integration.

“Strengthen the integration of FP in the care package for mothers and children under 5 years of age at the community level in all districts,

Introduce injectable contraceptives in the PMA of health huts” action Plan 2012–2020, Niger

However, In Burkina Faso, two of the nine documents consider the continuum of care. These documents include the Reproductive Health Policy and Standards (PN-RH) and the Integrated Reproductive, Maternal, Newborn, Child, Adolescent, Youth, and Elderly Health Strategy Plan. They included guidelines covering health needs throughout their lives.

Patient focus

In all three countries, the majority of policy documents on MNCH and nutrition consider the comprehensive nature of care. Each policy document, in addition to addressing the central theme, incorporates related topics within an approach that considers holistic care needs. Policy documents on MNCH include guidelines on FP and nutrition.

“ANC, childbirth, and postnatal consultations should be used to provide comprehensive care. The same applies to hospital care: Specific interventions (FP, PMTCT) must integrate all relevant services for these targets”. RMNCIAH, Burkina Faso.

For example, the National Strategy for Infant and Young Child Feeding (ANJE), December 2015, in Niger, recommends the following:

“In the health services, promotion and support for breastfeeding should be done during Antenatal consultations and PMTCT, Deliveries, Postnatal consultations and family planning vaccinations, Preschool consultations, Consultations for sick children, Treatment of acute malnutrition. " ANJE, December 2015, Niger.

At the health center level, this recommendation was translated into educational sessions on breastfeeding before the start of each vaccination session, ANC, and postnatal consultation, at least once a month.

The integration of FP with other services in health facilities is clearly stated in FP policy documents as a strategy to improve FP provision. However, the quasi-totality of FP guidelines does not address MNCH or nutrition services. They continued to focus on family planning.

The integration of FP is advocated in this statement in the following documents:

“Mobile and advanced strategy services, integration of FP services into other health services, and task shifting will be strengthened to provide FP services to populations living in remote areas.” (PNAPF, Burkina Faso).

This recommendation was implemented by training CHWs to offer contraceptive pills and Sayana Press. We have also delegated the task of authorizing the provision of long-term methods (IUDs, implants) to providers other than midwives.

“In order to avoid missed opportunities for clients who desire contraception, contraceptive products must be made available in all RH services (ANC, PNC, EPI, nutrition, STI management, etc.), in health facilities.” National Action Plan for Family Planning (2015–2020), Côte d’Ivoire.

This recommendation is being implemented in health centers by promoting FP awareness among women at vaccination clinics and by making contraceptive methods available at ANC postnatal clinics.

Standardised care delivery

Policy and strategy documents are the main tools used to provide a vision and direction for healthcare. However, none of the documents analyzed in our study provides clear guidance on how providers should offer integrated MNCH, FP, and nutrition care to mother-child pairs in health facilities. Furthermore, none of the documents provide guidelines on composite indicators for MNCH, family planning, and nutrition services or how providers should collect them.

Discussion

The objective of our study was to analyse the integration of MNCH, FP, and nutrition in policy documents in Burkina Faso, Côte d’Ivoire, and Niger. Our results show that care integration is described in most policy documents; however, the levels of integration vary.

Most family planning and nutrition guidelines focus on these main themes. This can be explained by the document elaboration process. In fact, most strategy and policy documents are developed by experts in the field; therefore, other fields are sometimes neglected or forgotten. Previous studies in Tanzania on mainstreaming have shown that apart from their own areas of expertise, actors in the ministries of health and education were limited in formulating guidelines for mainstreaming interventions for adolescents [32]. In addition, the lack of joint planning of the different programs due to the verticality of the programs, the specificity of the document, the subregional requirements of certain donors, and the lack of leadership of the Ministry of Health are factors that could explain this lack of integration in the policy and strategy documents. Another factor noted in previous studies is the fact that in national policies, information about some programs is often fragmented or incomplete [76]. The analysis of the policy documents showed that most of them did not consider the integration of services. However, these documents serve as guides for the provision of care by healthcare providers. Therefore, it would be useful to revise these documents, focusing on the integrated provision of care, if we want this to be effective in health centers.

Therefore, a participatory process that involves all stakeholders in the development of policy documents is required. In our case, the development of guidelines for the provision of integrated care should bring together stakeholders in RH, FP, and nutrition.

Furthermore, policy documents do not provide guidance on the integrated care delivery process. Cooper (2017) corroborates these findings in Kenya. He found that, at the policy level, the Kenyan Ministry of Health has recommended integrated service delivery since 2009, with the national integration of reproductive health and HIV/AIDS, but the detailed operational guidelines did not clearly address FP and nutritional components [31]. In Kenya, an Asiki study found that the integration of cardiovascular disease prevention and control at the primary healthcare level was not explicitly mentioned in policy documents [29]. However, as Suter et al. highlight, standardized care delivered by interprofessional teams promotes continuity of the care process [46]. de Jongh TE pointed out in his study, adequate training of providers with clear care guidelines is essential to provide the knowledge and skills needed to offer integrated services [77].

Therefore, it is time to review policies by reviewing national reproductive health policies (PN-SR) and integrate a vision on the provision of integrated care. Tani S. et al. recommend the review of current policies and protocols for integrating maternal nutrition intervention into ANC [78]. To ensure better implementation of this policy of integration of mother-child care in health centers, it is necessary to develop integrated training modules and tools for providers, as the tools currently available do not systematize the offer of integrated services. The definition of composite indicators for MNCH, family planning, and nutritional services is a prerequisite for tool development. This action requires the participation of all stakeholders, namely, maternal and child health, nutrition, and family planning.

This participatory process will result in clear service integration guidelines that facilitate the delivery of integrated care at health facilities.

The potential gaps between policy recommendations and implementation remain in the lack of clear guidelines describing the implementation of policies and other factors related to ward capacity (inadequate buildings) and care providers (insufficient staff and lack of commitment). This study had several limitations. The restriction of document selection to policies valid in 2018 excluded historical documents that could have provided insights into the evolution of integration approaches. Regarding the analytical approach, we limited our framework to three of Suter’s ten principles for the successful integration of health systems. A more comprehensive analysis using more principles can yield additional insights into service integration in policy documents.

Despite these limitations, our findings provide valuable insights into how MNCH, FP, and nutrition service integration is addressed in policy documents across Burkina Faso, Côte d’Ivoire, and Niger, while highlighting important areas for policy improvement.

Conclusion

This evaluation assessed the extent to which national policy documents and strategic plans address the integration of maternal and childcare (MNCH), family planning (FP), and nutrition services. The integration of services is a fundamental principle reflected in policy guidelines on MNCH, FP and Nutrition. Therefore, it is time to update national policies by including a vision of integrated service delivery of maternal and child health, family planning, and nutrition services. Specifically the FP guidelines should integrate other themes like nutrition and MNCH to exploit every opportunity to guarantee the provision of integrated care in health centres. National policies must define protocols for delivering integrated services at each level of health system (peripheral centers and district hospital ).

The revision of national policies on MNCH, PF, and nutrition requires the participation of all the stakeholders. This participatory process will result in clear service integration guidelines that will facilitate the delivery of integrated care at health centers. The participation of all stakeholders can lead to pooling of financial, material, and human resources, which could minimize the budget for implementing integrated care.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author uponon reasonable request.

Abbreviations

ANC:

antenatal care

ANJE:

Alimentation du nouveau-né et du jeune enfant

BF:

Burkina Faso

CI:

Côte d’Ivoire

eMTCT:

Elimination of Mother-to-Child Transmission of HIV 

FP:

Family planning

MNCH:

Mother, newborn and child health

PMA:

Paquet minimum d’activités (minimum activities package)

PNC:

Postnatal care

PPFP:

Postpartum family planning

READ:

Ready materials, Extract data, Analyze data, Distill results

RH:

Reproductive health

SRMNIA-PA:

Reproductive, Maternal, Newborn, Child, Adolescent, Youth and Elderly Health

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Acknowledgements

The authors thank the Bill & Melinda Gates Foundation and all consortium partners of the INSPiRE Initiative, including IntraHealth International, Institut de Recherche en Science de la Santé, Helen Keller International, and PATH. We also thanks, Elizabeth Capaci, Esther Tumbare, Karin Jacquin who help in writing of this paper.

Funding

The research that led to these results received funding from the Bill and Melinda Gates Foundation. HT received a grant from the WHO/HRP for financing the PhD study in Public Health.

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Authors and Affiliations

  1. Institut de Recherche en Sciences de la Santé (IRSS)/CNRST, Ouagadougou, Burkina Faso

    Halima Tougri, Rachidatou Compaoré, Wambi Maurice Evariste Yameogo, Abou Coulibaly, Danielle Yugbaré Belemsaga, Bertrand Meda & Seni Kouanda

  2. Université Saint Thomas d’Aquin (USTA), Ecole Doctorale Sciences, Santé et Technologies (ED/2ST), Ouagadougou, Burkina Faso

    Halima Tougri, Rachidatou Compaoré, Boukaré Congo, Denise Kpebo & Seni Kouanda

  3. Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso

    Wambi Maurice Evariste Yameogo, Boukaré Congo & Seni Kouanda

  4. Institut National de Santé Publique, Abidjan, Côte d’Ivoire

    Denise Kpebo

  5. IntraHealth International, Bureau Régional, Ouagadougou, Burkina Faso

    Isabelle Bicaba & Marguerite Ndour

  6. IntraHealth International, Chapel Hill, NC, United States of America

    Jen Snell

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  1. Halima Tougri
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Contributions

HT and MY collected and analyze the data. HT and RC performed the analyses and drafted the paper. SK obtained funding for the study. BC, AC, DYB, BM, DK, IB, MN and JS reviewed the paper. SK completed it in collaboration with all authors who read and approved the final version of the manuscript.

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Correspondence to Halima Tougri.

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The authors included seven females and five males and spanned multiple levels of seniority. While four of the authors specialize in health system research, three of them have experience in health policy. Six of the authors had more than ten years of’ experience in health research, while the others are under ten years. One of the authors was a sociologist with extensive experience in qualitative analysis. All authors have extensive experience in mother and child health service assessment in low-resource settings.

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Tougri, H., Compaoré, R., Yameogo, W.M.E. et al. To what extent are maternal and child health, family planning, and nutrition policies supporting integrated service delivery in Burkina Faso, Côte d’Ivoire, and Niger?. Arch Public Health 83, 101 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13690-025-01540-4

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Archives of Public Health

ISSN: 2049-3258