1. Measuring integrated service delivery: The need for the Integra Initiative Jonathan Hopkins International Planned Parenthood Federation Susannah Mayhew London School of Hygiene and Tropical Medicine Charlotte Warren Population Council

2. What is the Integra Initiative?  Flagship operations research initiative  Over five years (2008 – 2012)  Implemented in three countries in Africa:  Kenya  Malawi  Swaziland  Supported by the Bill & Melinda Gates Foundation  Managed by the International Planned Parenthood Federation (IPPF) in partnership with the London School of Hygiene and Tropical Medicine and Population Council  Included research, interventions, mentoring, capacity development and a “real life” approach to better understanding and evaluating service provision and client experiences

3. What gap did Integra seek to fill? Linkages: pre-Integra scenario Real commitment at global level to intensifying linkages between SRH & HIV at programmatic and policy levels. The rationale for doing so is clear but we need to gather evidence on how to link HIV and SRH. The Cochrane Systematic Review conducted in 2007 showed a lack of evaluative studies on the benefits of linking HIV & SRH. Integra goal: To strengthen the evidence of the benefits and costs of a range of models for delivering integrated HIV and SRH services in high and medium HIV prevalence settings for reducing HIV (and associated stigma) and unintended pregnancies.

4. 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?

5. Models of Integration evaluated Model 1: Integrating HIV into family planning services (Kenya only) Model 2: Integrating HIV into post-natal care services (Kenya & Swaziland) + + Model 3: Integrated HIV and SRH services (IPPF Clinics) (Kenya, Swaziland & Malawi) Model 4: Comparison of integrated and stand-alone HIV service models (Swaziland only) +

6. 2009201020112012 Health Facility Assessment time- series 2009-2012 (42 clinics) Community (HH) Survey Baseline 2009 N=2588 Community (HH) Survey Endline 2012 N = 3037 Client Flow time-series 2009-2012 N=9519 @ R0 Cohort studies 2010-2012 N=4763 @ R0 + 75 IDIs Costing Baseline 2009-2010 (42 clinics) Costing Endline 2011-2012 (42 clinics) Integra Data Collection, Kenya & Swaziland Cohort IDIs with sub-sample of WLHIV 2010-2012 N=150

7. 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.

8. An Innovative Solution 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 and understand what drives this and 2) evaluate the impact of the level of facility integration on the behavioural and health status outcome indicators.

9. Building the Index of Integration Range of services = 1) Antiretroviral therapy (ART); 2) Cervical cancer screening; 3) CD4 count services; 4) HIV/AIDS testing services; 5) STI treatment; 6) FP; 7) Post-natal care; 8) ANC DimensionIndicator NameData Source Physical Integration Service availability within MCH/FP unit Service availability in facility Range services provided in each consultation room ART location and referral Periodic Activity Review Costing data (clinic registers) Client Flow tool Temporal integration Range of services accessed dailyClient flow tool Provider Integration Range of services provided per clinical staff member Costing data (clinic registers) Functional Integration Range of services provided in one consultation Range of services provided in 1 visit Client flow tool

11. Baseline dataEndline data shows the same pattern Components of the Index Structural factors Actual delivery Two dimensions to the Index: Structural integration and functional integration… appear to behave differently Factor loading scores (correlation with the overall Index)

13. What explains the difference between structural and functional integration?... Providers and context... Individual provider competencies and attitudes... the systems/personal support providers get... staff turnover... influences of donors/NGOs/Government …. commodity supplies, are critical in explaining differences between clinics Integration is hard to sustain: improvements in clinic scores are not sustained over time.... Some case-studies of best practice are underway

14. Summary of Integra Findings We are going to hear more about the following in the presentations that follow: Integration is associated with: 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 Reducing stigma – if health staff are sensitive to fears and concerns and provide strong link to psychosocial support Successful integration requires a health system-wide commitment at both planning and implementation levels.

15. 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 more are under review and near submission….

16. 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

17. Thank you www.integrainitiative.org