Background:

1. How does HIV/SRH service integration impact workload? A descriptive analysis from the Integra Initiative in two African settings Sedona Sweeney1*, Carol Dayo Obure1, Fern Terris-Prestholt1, Vanessa Darsamo, Christine Michaels-Igbokwe1, Esther Muketo3, Zelda Nhlabatsi4, the Integra Research Team, Charlotte Warren2, Susannah Mayhew1, Charlotte Watts1, Anna Vassall1 1 London School of Hygiene & Tropical Medicine 2 Population Council, Washington DC 3 Family Health Options Kenya 4 Family Life Association of Swaziland

2. Background: • Integration of HIV and SRH services may yield improvements in efficiency • Despite a clear rationale for integration, there is scarce evidence on the costs and potential efficiency gains of integrated service provision Sweeney, S., et al. "Costs and efficiency of integrating HIV/AIDS services with other health services: a systematic review of evidence and experience." Sexually Transmitted Infections (2011)

4. Methods (1) • ‘HR integration’: the provision of multiple services by one staff member • Core MCH services: family planning (FP), post-natal care (PNC), antenatal care (ANC) • Non-core services: STI management (STI), voluntary HIV testing and counselling (VCT), provider-initiated HIV testing and counselling (PITC), cervical cancer screening (CaCx), and HIV treatment and care • HR integration score: Total number of non-core services available within MCH unit Total staff FTE allocated to these services

5. Methods (2) • We estimated the time required to deliver services through a mixed methods approach • Key informant interviews with staff, time sheets and direct observation of services • Process and output data collected from routine monitoring registers • Workload ratio: Actual staffing levels (available staff FTE) Estimated staffing requirements for services delivered Workload ratio > 1: some down time for staff Workload ratio < 1: staff are likely overworked

6. Methods (3): Data Analysis • Bivariate categorical analysis of workload ratios in facilities with high and low integration scores, by facility type • ‘More integrated’ (top 20% of integration scores) • ‘Less integrated’ (bottom 80% of integration scores) • Data analysed using Excel and Stata 13 • differences in workload estimates between HR integration category were explored, testing for significance at the p < 0.05 and p < 0.10 levels using Student’s t-tests, assuming unequal variance where applicable

7. Results

8. Improvements in Resource Integration from Baseline to Endline

9. Staff Time Observed per Consultation

10. Workload Indicators

11. Estimated Facility-level Workload Ratio at Baseline and Endline

12. Workload and Staffing, by HR Integration Category ‘More / Less Integrated’ *difference from ‘less integrated’ group significant at the p < 0.10 level (t = 1.79, p = 0.078) ** difference from ‘less integrated group significant at the p< 0.05 level (t = 2.05, p= 0.047)

13. 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

14. Acknowledgements Ministry of Health, Swaziland Ministries of Health, Kenya Family Health Options Kenya (FHOK) Family Life Association of Swaziland (FLAS) Learn more at: www.integrainitiative.org Support for this study was provided by the Bill & Melinda Gates Foundation.The views expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation For a copy of this presentation please visit same.lshtm.ac.uk