1. System-level Barriers to FP-HIV Integration Services in Malawi
Olive Mtema, Country Director, Health Policy Plus
21 July 2016
21st International AIDS Conference, Durban, SA

2. Background
Malawi has several policy documents addressing integration of family planning (FP) and HIV services
Clinical Management of HIV in Children and Adults (2014) recommends Provider-Initiated Family Planning (PIFP) within ART settings
WHO recommends FP and HIV services be integrated in areas of high HIV prevalence and high unmet FP need.
In 2015, the USAID-funded Health Policy Project undertook an assessment of the status of FP-HIV integration in Malawi.*
In Malawi
HIV prevalence among women: 12%
Unmet need for FP: 26%
Regionally
Unplanned pregnancies among HIV+ women: 51%-84%
Malawi Government has shown strong political will for service delivery integration. Of particular note it Malawi’s Clinical Management of HIV in Children and Adults, which directs ART providers to assume anyone 15 years and over are sexually active, and to proactively offer the client contraceptives at *each visit*. This is called provider-initiated family planning or PIFP. ART clinics are supposed to have at a minimum male and female condoms, and be able to offer injectables and referals for other methods.
Current indicators put Malawi among countries that need to integrate its FP and HIV services according to WHO recommendations.
In Malawi, USAID and UNFPA have been supporting integration in many districts, and in 2015, USAID requested the Health Policy Project to assess the status of FP-HIV integration in Malawi. This presentation is covering a subset of those results with a specific focus on the reproductive rights of PLHIV.
*Report: Irani, L., E. McGinn, M. Mellish, O. Mtema, and P. Dindi Integration of Family Planning and HIV Services in Malawi: An Assessment at the Facility Level. Washington, DC: Futures Group, Health Policy Project.

3. Methodology
41 health facilities of varying client volume across 9 districts and 3 regions
Government health centres & hospitals
Private hospitals/health centres
Integrated health centres
Mixed-method approach
41 Facility audits
122 Provider interviews, 41 In-charge interviews
425 Client flow analysis and interviews
58 Mystery client visits/interviews
3 FGDs with HIV+ clients
Data were collected from a purposive sample of 41 public and private facilities across nine districts of Malawi.
Facilities ranged from large high-volume hospitals to small health posts.
Data collectors conducted 41 facility audits, 41 interviews with facility in-charges, 122 interviews with providers, 425 client exit interviews.

4. RESULTS
Results will be presented in line with selected WHO’s health systems building blocks as shown:
Leadership and Governance
Human Resources for Health
Service Delivery
Commodities
Information
Financing

5. Workforce (HRH) Lack of training
In charges: only 39% had received training on FP/SRH/HIV integration
In charges: 20% had received no FP training
Providers: only 24% had received training on FP/SRH/HIV integration
Providers: 21% had no FP training
Affects service priorities and client choice
Providers mainly counseled ART clients on condoms, injectables, and pills; fewer mentioned female sterilization (63%), IUDs (55%), or vasectomy (44%)
High volume of clients exceeds provider availability
ART client waiting time ranged from 0 – 351 minutes (almost 6 hours!)
Average contact time with ART provider: minutes
FGD participants reported ART clinics not opening on time, closing early, or sleeping overnight to get services
Interview with in-charges of 41 health facilities revealed a gap in their knowledge of integrated service delivery with less that half of them indicating that they have never had training on FP/SRH/HIV integration.
In regards to health workforce, mystery client findings revealed yet another gap in provider knowledge of PIFP, which is heavily impacting its implementation.
Another need for information by providers can be evidenced through data on referrals: most health workers had little information about where and when those other services could be accessed, despite referring out their clients.
Providers are overwhelmed with volume of clients

6. Organization of services
83 % of providers reported ART services had been reorganized to accommodate FP
protocols (42%)
training (48%)
expanded ART service delivery time (15%)
Referral for FP services was routine, however providers lacked important details
44% knew: times referred FP services were available
29% knew: transport costs to reach referred FP services
14% of providers had no knowledge of referred services

7. Service Delivery Various models of integration in play
Same location, same day (fully integrated)
Same facility, different room, same day (internal referral)
Same facility, different day (parallel services)
Referred out to different facility/pharmacy
BLM (Marie Stopes) outreach services at same facility; (dedicated event)
Many facilities provide services in multiple ways
Level of integration often depends on type of FP method
Larger facilities (hospitals) don’t offer FP at the ART clinic, clients are referred to a dedicated FP room (internal referral)
Health centres largely referred out for sterilisation services and often IUDs
Many facilities provides services in multiple ways (i.e. multiple models in use in one facility)
Health centres often relied on referrals for long acting and permanent methods (sterilisation, IUDs, and sometime implants).
Many public facilities were also relying on BLM outreach services – where a Marie Stopes affiliate would visit the service delivery point on a specific day (usually monthly) to provide methods.

8. Service Delivery (2) Quality of services need improvement
Mystery clients reported harsh treatment and/or being denied services because they were not registered at that facility
Only 2 out of 58 mystery client visits reported provider- initiate FP
In exit interviews, only 14% of women reported being asked about FP/fertility intentions at that visit
Almost half of women reported in exit interviews that they had not being told about side effects of their current method
Focus group participants talked about often not getting FP after their ART clinic because queues too long/FP clinic had closed
Clinic hours and provider availability were also identified as hindering FP service provision for ART clients.

9. Commodities HIV FP Integrated Services Stock Outs
85% of facilities had FP* available at HCT clinic (n=41)
85% of facilities had FP* available at ART clinic (n=41)
75% of FP rooms observed offered HIV services (n=33)
*Note: FP included condoms; only 4 HCT and only 11 ART clinics had injectables as per nat’l guidance; only 7 ART clinics has a range of method choice available
Stock Outs
44% of facilities providing FP reported FP stock-outs or expired products in past 3 months (17/39)
High stock out rates of injectables (47%), pills (47%) and condoms (47%)
Facilities also reported stock outs of (or expired) HIV-related commodities
HCT kits 34%
ARVs 24%
OI drugs 15%
Using facility audits, we looked at whether family planning methods and supplies were available at the HCT and the ART clinics/rooms.
While we can claim that a high number had family planning methods, if you look at which methods, these are mainly male and female condoms.
Seventeen facilities out of 39 that provided FP (44%) reported experiencing stockouts or expired products in the past three months.
Of these 17 facilities, almost half experienced stock outs of injectables, pills, and male condoms, almost one third had stockouts of implants and female condoms

10. HMIS
Multiple paper registers at HCT, ART, and FP clinics, complicating paperwork for providers
At HCT clinics, data collectors reviewed registers (n=33)
70% had registers that incorporated FP column
9% used separate FP register
21% had no mechanism to register FP provision
At ART clinics, data collectors reviewed registers (n=18)
17% had registers that incorporated additional FP (beyond condoms, injectables)
23% maintained a separate FP register
11% had no mechanism to register FP provision
N=17, data collectors not able to check register (not available, locked away, access denied)
Several facilities had no system to capture referrals for FP
HMIS not adequately capturing service integration
Data collectors looked at clinic registers to see how integration statistics were being captured. At most facilities, there were multiple paper registers, complicating paperwork for providers.
Many facilities had updated FP, HCT, or ART client registers to accommodate integrated services.
To align with the national guidelines, ART clinics were supposed to include extra columns to indicate condom provision and injectables provision.
However a few were using separate FP registers to note FP service provision, and some had no mechanism to report FP provision. In several facilities, data collectors were not able to view the registers either because it was mission or note out yet for the day, or the provider did not allow it.
Moreover, a few facilities were operating without registers on the day of data collection. This suggests current monitoring and evaluation systems and data are not capturing the full picture of how integrated services are being operationalized.

11. WHAT HAVE WE LEARNT?

12. What have we learnt?
Malawi’s policy documents aren’t resulting in a strong integration of services at the facility level
There is need for improved and detailed referral mechanisms at different levels of facilities
Commodity stock outs continue to hinder service delivery (esp. public sector)
Improve logistics system to address stock outs
More provider training on PIFP is needed
Improve patient registers and other M&E systems
Improve quality of services and promote a client- centered/rights-based approach
Although national policies support FP-HIV integration, systems at the facility level are not yet adequate to fully implement integration. The study and analysis offers recommendations of how facilities can improve their organization of services, strengthen both internal and external referral processes, increase training of providers on PIFP, improve patient registers and other M&E systems to better capture data, and address both FP and HIV commodity and supply stock outs.

13. Thank You