1. Testing Efficiency Indicators
Evaluating the Costs and Efficiency of Integrating Family Planning (FP) into Antiretroviral therapy (ART) services in Zambia:
Testing Efficiency Indicators
Dr. Sophie Faye, Dr. Benjamin Johns, Dr. Elaine Baruwa, and Ms. Kelley Ambrose
Health Finance and Governance Project
AIDS 2016 Conference - Durban

2. Study Background
FP/ART integration supports key prevention goals and PEPFAR recognizes integration of FP and ART services as a key strategy
Integration may increase efficiency of resources used, but evidence of efficiency difference across different models is limited
High adult HIV prevalence in Zambia
Unmet need for FP estimated at 27 percent
Substantial population of HIV-positive women of reproductive age in need of FP services.

3. Objective
Quantitatively assess the relative efficiency of two different models of integrating ART and FP services
One Stop Shop (OSS) model: FP counselling and method offered to patients with identified needs inside the ART clinic, by trained ART providers
Internal referral (IR) model: After being counselled on FP, patients with identified needs are referred from the ART clinic to the FP clinic in that same facility to receive FP method

4. Underlying assumptions
The study focused on the process of providing FP services in the two different models.
No attempt to evaluate the content of the FP services or its quality
The inability to provide FP counselling, FP method or FP referral in the ART clinic is considered “missed opportunity”
Short term methods only: female condoms, injectables and pills
Efficiency defined as:
Minimizing the level of resources required per unit of output produced, or
Producing more output per unit of resource used.
Explain better about the missed opportunity to say why we choose that. All the systems are in place if the service do not happen then it is a waste .

5. Study design
Non-randomized sampling of 10 health facilities (3 OSS and 7 IR ) : each with an ART and a FP clinic
12 months data coverage: October September 2014
Unit of analysis with respect to efficiency is the ART clinic
Population of interest: female ART patient of reproductive age

6. Methods
Mix data sources : 900 Patient record reviews, 150 patient exit interviews with time motion component , 20 provider interviews, HMIS and facility cost data
Top down costing approach
Costs include labor, drugs and medical supplies, training and supervision
Efficiency across models measured using :
Percent of missed opportunities for FP counselling
Unit cost per ART patient counseled on FP or provided with an FP method

7. Findings: Percent of Missed Opportunities for FP counselling
Calculated for the Non-FP users, not pregnant ART patients of reproductive age
No statistically significant difference across models
P-value 0.43 with Mann-Whitney U test
Many women are not getting FP counselling:
Wide variations across facilities : 8% to 88%
Median of 36% for the OSS model and 50% for the IR model

8. Findings: Unit Cost per ART Patient Receiving FP Services
With current level of FP service provision, no statistically significant difference (P-value 0.73) in the average unit cost across models
Average unit cost per patient per year
The OSS model is not necessarily more or less efficient than the IR model
With current level of FP service provision, no statistically significant difference in the average unit cost across models
ART + FP counseling
ART + FP counseling + method
IR model sites
$ 260
$ 267
OSS model sites
$ 258

9. Discussion
There could be potential efficiency gains from the OSS if missed opportunities were reduced
But incremental costs for the integration are very low
The FP clinic will still have to function under the OSS model “limiting” the gains when HIV+ population with FP need is not large
Benefits to the patient under OSS (decreased stigma, patient cost savings..) might be a more appealing aspect of OSS model than “costs savings”.

10. What did we learn? Integration is at the level of the provider
The systems might be in place but
the providers need to actually offer
the services
Providers need to be sensitized to adequately record the services they provide at the time of delivery
We can’t track/cost what we don’t count
Need to design a formal referral system as part of the integration program
Adequate methods and tools for better patient referral
Integration is a larger concept so we as implementers need to make sure that when we put in place the systems we have the possibility to check

11. Study Limitations Limited sample size
Few facilities were implementing OSS at the time of the study
Difficult to generalize the results but can shape further programs
Low FP data quality at ART clinics
Inconsistent recording of FP service
Provision
Poor organization of records

12. Acknowledgements
This work was funded by the USAID Office of HIV/AIDS in Washington
The team wants to thank:
The Zambian Ministry of Health and Ministry of Community Development, Mother and Child Health, as well as the District Medical teams for Lusaka, Mongu, and Kabwe.
The USAID Zambia Health team
The FP integration team at both CIDRZ at the former ZPCT II Project
The local data collection team lead by Mr. Petan Hamazakaza
All the people who reviewed this work

13. Thank you