www.integrainitiative.org Charlotte Warren Population Council Joelle Mak London School of Hygiene and Tropical Medicine

Integra research questions 1) What are the relative benefits of different models of integrated SRH and HIV services over separately provided services? Does integration lead to: increases in the numbers of clients using services; changes in the profile of clients attending services; increases in the range of services accessed by clients; improvements in the quality of services? 2) In the target populations, what is the impact of integrated services on: HIV related risk behavior; HIV related stigma; unintended pregnancy? 3) What is the cost, feasibility and cost-effectiveness of providing selected integrated services: What is the cost of integrating HIV and/or SRH services with existing services? How do costs vary by model of integration? Does integration result in a more optimal utilization of existing infrastructure and human resources?

The challenge of ‘embedded’ research ‘Real’ setting: comparison facilities contaminated: by additional Govt/donor activities on integration by staff actions at individual facilities Implementation of intervention varied across facilities motivation, stock-outs, staff turnover etc. Degree of integration achieved & sustained at individual clinics varied and changed over time ... As a result, we were not confident that the levels of integration achieved in intervention facilities would be significantly different from those in comparison facilities. Susie speaks from here

An Innovative Solution: The Integra Index Independent measure to account for actual degree of integration at each facility over time. Range of clinic-specific data available at different time-points = construct a multi-dimensional ‘Index’ to measure a continuum of achieved integration. Facility scores (n=42) are generated at multiple time-points and used to: 1) assess the extent of service integration achieved within facilities over time and understand what drives this; and 2) evaluate the impact of the level of facility integration on the behavioural and health status outcome indicators.

Policy and program implications Structural (including equipment and supplies) and training inputs are insufficient for achieving integrated service delivery. Monitoring and evaluation must therefore also measure functional integration. Achieving functional integration requires mechanisms to enhance the motivation, communication and team-working of health workers. Achieving functional integration requires attention not only to staffing numbers and training (the usual focus of “success” in health systems and services), but also developing mechanisms to enhance the motivation and communication of health workers. Currently providers are developing their own, ad hoc, strategies to enable integration without systematic health systems support. These should be formalised and lessons can be learned from providers reporting good teamwork to cope with increased workload, stress and waiting times

Importance of People –ability to cope Systems software issues are critical for high functioning integration: Better teamwork and communication: Nowadays we communicate…and that’s been really helpful I think. You don’t feel alone on the job. It never used to happen before. (Nurse, Health Centre, PNC, Kenya) Better job satisfaction and staff motivation …where there is no integration there is that boredom because of doing one thing and there is no change. In integration […] it keeps on rotating in your mind…and you enjoy the work. It boosts my morale, because the monotony is not there. (Nurse, Hospital, FP, Kenya) It was the qualitative interviews that revealed ways in which providers were able to cope with the additional challenges of integration. In particular better teamwork and communication were critical. But also integration seemed to provide more job satisfaction so staff were more motivated to work through problems. systems software = People! CONCLUSIONS: Achieving functional integration requires attention not only to staffing numbers and training (the usual focus of “success” in health systems and services), but also developing mechanisms to enhance the motivation and communication of health workers. Currently providers are developing their own, ad hoc, strategies to enable integration without systematic health systems support. These should be formalised and lessons can be learned from providers reporting good teamwork to cope with increased workload, stress and waiting times

Implications for policy Integration was not scaled up uniformly; readiness assessment should precede integration policy HIV/SRH integration may be most influential on staff workload for PITC, PNC and STI services Some of these increases, in particular increased staffing of HIV-related services, may have come at the cost of reductions of staff available for other services such as PNC, and lead to greater imbalances in staff workload within a facility However, policy makers should also be careful about overworking staff and assess integration in the broader context of HR planning So to summarize: We find some evidence to suggest that there is potential to improve productivity through integration, however with some significant challenges, and the pace of productivity gain slow. Our results indicate that integration might have the most impact on staff workload for PITC, PNC and STI services. However in some cases, we saw increased staffing of HIV related services come at the cost of reductions of staff time available for other services such as PNC, leading to greater imbalances in staff workload within a facility. We recommend that any efforts to implement integration therefore are fully assessed in the broader context of HR planning both within and between facilities to understand the impact on different staff cadres and to minimise displacement effects in order to ensure that neither staff nor patients are negatively impacted by integration policy.

Community level summary Need for FP and HIV/STI prevention High levels of need for FP which were largely met; Reduction in need for HIV/STI prevention and for dual need; Reduction in unmet dual need Among those with unmet needs: Reduced levels of missed opportunities for women who used services Low usage of services among men and low at endline among women Past year service use Reduction in service use for both men and women across both countries Demand for & Receipt of integrated SRH/HIV services Both demand and receipt reduced but more respondents received integrated services than those wanting them at endline. More receipt of integrated services came from RH users. More work needs to be done for men where demand for and provision of integrated services remain low.

Summary – Integra results: Better HIV testing outcomes & more consistent condom use Improved quality of care Improvements in efficiency through better use of human resources Improved teamwork and provider motivation - if they feel supported by their managers Ensuring client choice: e.g. preferences of women living with HIV for integrated care within a specialist HIV site Evidence reveals how complex and delicate the issue of stigma is as it relates to providing integrated HIV and SRH services Reducing stigma – health staff must be sensitive to fears and concerns and provide strong link to psychosocial support More provider initiated provision of integrated services (MNCH) Summary of findings from Integra Successful integration requires a health system-wide commitment at both planning and implementation levels We are starting to build a fuller picture of what needs to be done, we need to understand that individual items that are recommended should not be seen in isolation but as within a broader context and the implications with each other.

Please see the Integra website for further information: www Please see the Integra website for further information: www.Integrainitiative.org A summary list of publications to date is provided below: Warren, C., Mayhew, S.H., Vassall, A., et al (2012). Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland.BMC Pub Health, 12(973). Sweeney, S., Obure, C.D., Maier, C., et al. (2012). Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience. Sex Transm Infect, 88, 85-99. Obure, C.D., Vassall, A., Michaels, C., et al (2012). Optimising the cost and delivery of HIV counselling and testing services in Kenya and Swaziland. Sex Transm Infect, 88, 498-503. Church, K., Lewin, S. (2010). Delivering integrated HIV services: time for a client-centred approach to meet the sexual and reproductive health needs of people living with HIV? AIDS, 24,189-193. Church, K., Mayhew, S.H. (2009). Integration of STI and HIV prevention, care, and treatment into family planning services: a review of the literature. Studies in Family Planning, 40, 171-186. Mak, J., Birdthistle, I., Church, K., et al (2013). Need, demand and missed opportunities for integrated RH-HIV care in Kenya & Swaziland: evidence from household surveys. AIDS 27(Suppl1):S55-S63 Warren, C.E., Abuya, T., Askew, I., Integra Initiative (2013).FP practices and pregnancy intentions among HIV-positive and HIV-negative postpartum women in Swaziland: a cross sectional survey. BMC Preg & Childbirth.13 (150) Colombini M., Mutemwa R., Kivunaga J., Stackpool-Moore L., Mayhew S.H. Experiences of stigma among women living with HIV attending SRH services in Kenya: a qualitative study. In press BMC: Health Services Research Ndwiga C., Abuya T., Mutemwa R. et al. Exploring experiences in peer mentoring as a strategy for capacity building in sexual reproductive health and HIV service integration in Kenya BMC Health Services Research Birdthistle, I J., Mayhew S, Kikuvi J, et al (2014). ‘Integration of HIV and maternal health care in a high HIV-prevalence setting: Analysis of client flow data over time in Swaziland’. 2014 BMJ Open Colombini M., Mayhew S.H., Stockle H., Zimmerman C., Watts C. (2014) Factors affecting adherence to short-course ARV prophylaxis for preventing mother-to-child transmission of HIV in sub-Saharan Africa: A review and lessons for future elimination. In press: AIDS Care Kimani, James Warren, C., Abuya, T., Mutemwa, R., Mayhew S., and Ian Askew . Family planning use and fertility desires among women living with HIV in Kenya .under review BMC Public Health 2015

Cost and Efficiency Papers Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience. Sexually Transmitted Infections (2011) The impact of HIV/SRH service integration on workload: analysis from the Integra Initiative in two African settings. Human Resources for Health, 12(1), 42 2014 The costs of delivering integrated HIV and sexual reproductive health services in resource-limited settings. Revise and Resubmit PLOS One Optimising the cost and delivery of HIV counselling and testing services in Kenya and Swaziland. Sexually Transmitted Infections 88(7): 498-503. Do integrated HIV and SRH services achieve economies of scale and scope in practice? Under review Sexually Transmitted Infections Does integration of HIV and sexual reproductive health (SRH) services increase health facility technical efficiency? An application of a two-stage semi parametric approach incorporating quality measures. Under review Social Science and Medicine Contact info: Sedona.Sweeney@lshtm.ac.uk; Carol.Obure@lshtm.ac.uk

Acknowledgements: Bill and Melinda Gates Foundation Hard work of the entire Integra team: IPPF: Mathias Chatuluka; Taghreed El-Hajj; Phelele Fakudze; Jon Hopkins; Sheena Kakar; Irene Kamanga; Esther Kiragu; Lungile Mabuza; Agnes Makau; Edward Marienga; Zelda Nhlabatsi; Grace Neburagho; Stephen Njoka; Kevin Osborne; Lawrence Oteba; Lucy Stackpool-Moore; Ale Trossero; Muthoni Wachira. London School of Hygiene & Tropical Medicine: Linda Amarfio; Isolde Birdthistle; Kathryn Church; Manuela Colombini; Justin Fenty; Natalie Friend du Preeze; Joshua Kikuvi; Joelle Mak; Fiona Marquet; Susannah Mayhew; Christine Michaels-Igbokwe; Richard Mutemwa; Dayo Obure; George Ploubidis; Sedona Sweeney; Fern Terris-Prestholt; Keith Tomlin; Anna Vassall; Charlotte Watts; Weiwei Zhou. Population Council: Timothy Abuya; Ian Askew; Lucy Kanya; James Kimani; Jackie Kivunaga; Brian Mdawida; Charity Ndwiga; and Charlotte E Warren. Ministries of Health in Kenya, Malawi and Swaziland

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