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Reflections on the Integration for Impact Conference

by on October 3, 2012

Blog contribution by Heidi Reynolds, Sr. HIV/AIDS Technical Specialist for MEASURE Evaluation

From 12-13 September 2012, Nairobi, Kenya, was host to the first ever Integration for Impact Conference, integration of sexual and reproductive health services and HIV in sub-Saharan Africa.  It was fitting for this conference to be in Kenya, a country that has been at the forefront of testing and implementing integrated approaches and developing national guidelines. It is also significant for me as Kenya is where my own research work on integration began, over 10 years ago, with the Division of Reproductive Health in the Ministry of Health, National AIDS and STD Control Program (NASCOP) and FHI 360 (where I was working at the time). We were studying the feasibility of integrating family planning services into voluntary counseling and testing services, and at the time we were venturing into new territory.

Remarkable progress has been made in the last 10 years. Ten years ago, pilot tests, operations research, and modeling outpaced integrated policies and programing. Today, integrated health services is a globally recognized strategy for gaining efficiencies and improving the continuum of care. There has been a complete 180 degree turn in support for SRH integration by HIV advocates. Integration now features prominent in global health initiatives. There are many programmatic experiences of integrating sexual and reproductive health services and HIV, many of which were highlighted at the conference.

Recognizing the need for more evidence of the effectiveness and cost-effectiveness of integration, some more rigorous trials of integrated SRH-HIV models were launched. The Integration for Impact conference was timed to coincide with the presentation of results from two major studies: A cluster randomized control trial of integrating family planning in to HIV care and treatment in Nyanza, Kenya (FACES) and a cluster randomized control trial of integrated antenatal care and HIV treatment integration (SHAIP). Preliminary results from a third major study in Kenya and Swaziland, the Integra Initiative, were also presented. Integra is studying the cost-effectiveness of integrated family planning and post-natal services and integrated HIV and post-natal care.

The findings of those studies suggest more effective contraceptive use in the integrated FP-HIV care and treatment model, but no difference on pregnancy incidence. The integrated ANC and HIV treatment study demonstrated few statistically significant difference between groups on outcomes along the PMTCT cascade or on maternal or infant outcomes, except the intervention group experienced timelier enrollment in HIV treatment and better ART adherence. On the other hand, there were strong indications that integration was associated with more positive male attitudes; was more acceptable to providers; increased client satisfaction; and resulted in clinics with more equipment, supplies and trained staff than comparison groups. More details and findings from the cost-effective analyses from these studies are needed.

MEASURE Evaluation contributed information about how information systems can be strengthened to support integration. Upama Khatri, Monitoring and Evaluation Advisor, and colleagues had a poster about a case study from Cote d’Ivoire and how interlinked patient monitoring systems may help provide more comprehensive care for clients and strengthen the information system. Catherine Mbaire, Senior M&E Associate, and colleagues highlighted how the recently pilot tested Toolkit for Rapid Monitoring of AIDS Referral Systems (R-MARS) will help programs assess referral capacity and improve referral. I presented on how existing M&E approaches can be used to gain more country ownership of integration through country-driven approaches to planning, implementing, and monitoring and evaluating integrated services. I also presented on how an organizational network approach may be used to improve coordination and integration of services. Other non-MEASURE Evaluation presentations also suggested how electronic data bases, specifically a clinical management information systems, may improve availability of information (Muketo and colleagues). FHI 360 demonstrated how they were monitoring scale up of integrated HIV care and treatment and FP by using the results from the initial pilot test to set targets (Gitau and colleagues). Another FHI 360 study assessed the feasibility using existing program data to populate six family planning-HIV integrated indicators (Adamchak and colleagues).

Other important themes were evident:

  • Calls for more process-type evaluations that can describe the relationship between program inputs and outputs and provide insight into what it is about integrated programs that seems to work or not.
  • Acknowledgement of the historical integration “pregnancy bias,” where many SRH-HIV integration efforts focus on preventing unintended pregnancy or are offered during the antenatal or postpartum periods. Viable approaches and experiences to integrating cervical cancer screening, screening for gender based violence, and the need to ensure key populations (MSM, FSW, IDU) benefit from integrated services were highlighted.
  • Tackling stigma and discrimination and active inclusion of male partners are increasingly recognized as key factors to address to ensure that integration achieves its full potential.
  • Tension remains regarding integration approach and terminology. “Integrated” was typically used to refer to the availability of services all in one location, if not also by a single program. Whereas “non-integrated” was really more of a referral-based model.  There were inspirational calls for integrated models that resemble the “one stop shop” approach where all clients’ needs are met under one roof. Discussions about the role of referral-based (or linkages) models were underrepresented.
  • The Integra Initiative is developing an “integration index.” A well validated integration index has the potential to help programs standardized how they report about what they have done in their integrated programs (e.g., we have elements a, b, and c but not d) and to monitor implementation over time.

The conference was exciting and historic, but all the evidence and program experiences leaves us with a lot to consider about how best to plan integrated interventions that respond to the specific health system context, and also to evaluate them in such a way that helps us understand why or why not particular approaches were effective in changing health outcomes, particularly outside the controlled research process and as countries look to scale up their interventions.

What are your thoughts on how best to plan integrated interventions that respond to the specific health system context? What is your opinion on how interventions should be evaluated to understand effective approaches? 

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