Assessing integrated SRH and HIV services in Kenya, Swaziland and Malawi: Evidence on efficiency and cost Timothy Abuya on Behalf of the Integra Team

5 year operations research initiative, managed by IPPF in partnership with London School of Hygiene and Tropical Medicine and Population Council Goal: To strengthen the evidence of the benefits and costs of a range of models for delivering integrated HIV and sexual and reproductive health (SRH) services in high and medium HIV prevalence settings for reducing HIV (and associated stigma) and unintended pregnancies. (Kenya, Swaziland & Malawi) Objectives: 1.To determine the benefits of four different models of integration to increase the range, uptake and quality of selected SRH and HIV services. 2.To determine the impact of different integrated services on changes in HIV risk behaviour, HIV-related stigma, and unintended pregnancies. 3.To assess the efficiency of different operational models for delivering integrated services in terms of cost, use of existing infrastructure and human resources. 4.To increase the use of research findings by policy and programme decision- makers through the involvement of key stakeholders. What is Integra?

Models under evaluation

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?

Research Activities (integration and control sites) Economics in all countries Facility assessments (all) (1/yr) & client-flow (2/yr) Checklist, provider interviews, client- provider observations, exit interviews Cohort surveys with PNC & FP service users; (Y2,3&4) Cross-sectional survey with HIV+ users (Y2,Y4) Additional qualitative provider interviews Community surveys (Y2 and Y4) Additional ad hoc qualitative studies Additional qualitative client interviews

Value for money

Largely supports current global policy and further efforts to integrate, and a number of integrated HIV services have been shown to be cost-effective, but nevertheless has substantial gaps. The highest quality evidence addresses services which require integration from a clinical perspective, including: HIV CT in ANC services as part of the provision of PMTCT Making FP services available to HIV-positive clients Emerging evidence about efficiency gains from integrating CT more broadly into SRH Sweeney S, Obure CD, Maier CB, Greener R, Dehne K, Vassall A. Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience. Sex Transm Infect Mar;88(2): Evidence to date

However.. Little is known about the comparative efficiency of differing integration models Substantial evidence gaps remain on efficiency gains from integration for HIV care and treatment and services for populations at higher risk of HIV exposure. Almost no research to date examining efficiency gains from integration beyond the service level (in management systems etc.) and economic gains to HIV service users – despite these both being a key potential area for gains. Finally, the best models for implementing integration in a way that does not overload some service providers, but fully utilises others still have to be properly evaluated

Some preliminary results Study compares the economic costs of delivering HCT services through integrated PITC and VCT within the same site at 28 health facilities in Kenya and Swaziland.

Methods Output measures and annual economic costs of providing PITC and VCT services were collected from 28 health facilities providing both PITC and VCT services Data was collected from routine monitoring data for the 2008/09 financial year and analysis conducted from the providers perspective Total annual economic costs, unit cost per PITC and VCT client counseled and tested and cost per client testing HIV positive identified were estimated

Unit costs per PITC/VCT client C&T: Kenya

Unit costs per PITC/VCT client C&T: Swaziland

Average staff workload – Clients per day per full time staff equivalency (Kenya)

Average staff workload – clients per day per full time staff equivalency (Swaziland)

Summary of findings Findings suggest that integrated PITC services compare favorably with stand- alone VCT both in terms of cost per client counseled and tested and cost per HIV positive client identified Variation in costs is driven by human resource utilization Overall the variation in unit costs suggests that there is considerable room for efficiency gain in HCT services.

Policy and practice implications Integrated PITC and stand alone VCT are not substitutes for each other in all settings. Effectiveness and desirability of services from client perspective has to be taken into account as well as costs. Where demand for HCT is low, thought should be placed on ways of either better locating stand-alone HCT services or to adding more services to stand- alone sites, to ensure that staff are used to a maximum. Care should be taken not to expand HCT where services are already overstretched, unless additional staffing can be made available.

Conclusions Analysis highlights need for further efforts to assess efficiency and improve resource use of different HCT services. Important to take into account local demand in terms of what clients are accessing and local supply to ensure human resources are used in the most efficient way. Maintain attention to issues of quality, confidentiality and choice in provision of all types of HIV counselling and testing (HCT and PITC).

But integration is not without its challenges...