INTEGRATION OF HIV AND REPRODUCTIVE HEALTH SERVICES: PRODUCTION PROCESSES IN FAMILY HEALTH OPTIONS KENYA CLINICS

by

Carol Atieno Obure

Submitted in partial fulfilment of the requirements for the degree of Master of Development Economics

at

Dalhousie University Halifax, Nova Scotia June 2009

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Appendices Copyright Releases (if applicable) DEDICATION

This thesis is dedicated to the loving memory of my father the late Allan Obure who always believed in me. Daddy, I wish you had lived to see this day.

To my mother, Florence Obure, Uncle, Joshua Mallet and Aunt, Elom Dope Akoumani. Thank you for your prayers and encouragement throughout this journey.

To my brothers Roy and Carl, this is to inspire you that with God all things are possible.

IV TABLE OF CONTENTS

LIST OF TABLES vii

LIST OF FIGURES viii

ABSTRACT ix

LIST OF ABBREVIATIONS USED x

ACKNOWLEDGEMENTS... xii

CHAPTER 1: INTRODUCTION 1

1.1 Background 1 1.2 Economics of Integrating HIV and SRH Services 3 1.3 Aims and Objectives of the Thesis 4

CHAPTER 2: CONCEPTUAL APPROACH TO INTEGRATION 6

2.1. Production Theory 6 2.2 Costs of Production 10 2.3 Joint Production 12 2.4 Economies of Scope 13 2.5 Transaction Costs Theory 14 2.6 Conclusion 19 CHAPTER 3: LITERATURE REVIEW 20

3.1. Defining Integration 20 3.2. Forms of Integration 21 3.3. History of Integration of Health Care Services 25 3.4 Rationale for Integrating HIV and SRH Services 27 3.5 Organization of HIV and SRH Services 30 3.6 Models of Integrated HIV and SRH Services 32 3.7 Challenges to Integration 36 3.8 Results of Integration Studies 37 3.9 Conclusion 51

v CHAPTER 4: BACKGROUND AND METHODOLOGY 53

4.1. Kenya 53 4.2. HIV in Kenya 55 4.3. National Response to HIV/AIDS 57 4.4 Organisation of HIV and SRH Services in Kenya 59 4.5 Thesis Aims and Objectives 60 4.6 Methodology of Study 61 4.7 Background on Family Health Options Kenya 63 4.8 Conclusion 64

CHAPTER 5: PRODUCTION PROCESS OF INTEGRATED HTV AND REPRODUCTIVE HEALTH SERVICES 66

5.1 Description of the Clinics 66 5.2 Output Data 72 5.3 Description of Production Processes 74 5.4 Output Data Analysis 78 5.5 Input Profiles 81 5.6 Discussion 85 5.7 Conclusion 88

CHAPTER 6: CONCLUSION 90

6.1 Background in Economic Theory 90 6.2 Literature Review 91 6.3 Background and Methodology 91 6.4 Production Processes of HTV and SRH Services 92 6.5 Conclusion 93

REFERENCES 96

APPENDIX A: PERIODIC ACTIVITY REVIEW TOOL 102

APPENDIX B: LIST OF KEY INFORMANTS INTERVIEWED 123

VI LIST OF TABLES

TABLE 3.1 DEFINITIONS OF INTEGRATION 22

TABLE 3.2 SUMMARY OF INTEGRATION STUDIES 38

TABLE 5.1 DESCRIPTION OF OUTPUTS 67

TABLE 5.2 SUMMARY OF CLINICS INCLUDED IN STUDY 69

TABLE 5.3 CD4 REFERRAL SITES 76

TABLE 5.4 SUMMARY OF CLINICS OUTPUTS FOR JAN - JUNE 2008 80

TABLE 5.5 KEY STAFF INVOLVED IN PROVISION OF SRH AND HIV SERVICES 81

TABLE 5.6 SUMMARY OF CLINICS LABOUR INPUTS 84

Vll LIST OF FIGURES

FIGURE 2.1 ISOQUANT MAP 9

FIGURE 3.1 STRUCTURAL INTEGRATION 24

FIGURE 3.2 COMPONENTS OF HIV AND SEXUAL REPRODUCTIVE HEALTH SERVICES ... 30

FIGURE 4.1 MAP OF KENYA'S HIV PREVALENCE BY PROVINCE 56

vm ABSTRACT

Integration of HIV and Sexual Reproductive Health services (SRH) has been advocated as a means of curbing the spread of HIV in high HIV prevalence settings while meeting the reproductive health needs of people living with HIV/AIDS. However, despite the benefits associated with integrating HIV and SRH services, there remains a dearth of economic evaluations of such integrated service delivery. This lack of economic analysis can be attributed to the major gap in knowledge of how resources are combined to produce such integrated services.

This thesis therefore aims to address this information gap by examining how resources are combined to produce integrated HIV and SRH services in six Family Health Options Kenya Clinics. The analysis of the production processes presented in this thesis is expected to inform future economic evaluations of various models of integrated HIV and SRH service delivery.

IX LIST OF ABBREVIATIONS USED

AIDS Acquired Immunodeficiency Syndrome

ANC Ante Natal Care

ARV Anti-Retroviral

ART Anti-Retroviral Therapy

CHW Community Health Worker

COW Community Outreach Worker

DRH Division of Reproductive Health

ERSWEC Economic Recovery Strategy for Wealth and Employment Creation

FACES Family AIDS Care and Education Services

FP Family Planning

FHOK Family Health Options Kenya

FPAK Family Planning Association of Kenya

GDP Gross Domestic Product

HBC Home-Based Care

HIV Human Immunodeficiency Virus

ICPD International Conference on Population and Development

IPPF International Planned Parenthood Federation

IUD Intrauterine Contraceptive Device

KAIS Kenya AIDS Indicator Survey

KEMRI Kenya Medical Research Institute

KNASP Kenya National AIDS Strategic Plan

MCH Maternal and Child Health

X MOC Models of Care for Integrating HIV/AIDS Prevention and Care into

Reproductive Health services

MOH Ministry of Health

NACC National AIDS Control Council

NASCOP National AIDS and STI Control Programme

01 Opportunistic Infections

PAR Periodic Activity Review

PITC Provider Initiated Testing and Counseling

PLWHA People living with HIV and AIDS ,

PMTCT Prevention of Mother to Child Transmission

PNC Post Natal Care

PSS Psychosocial Support

RH Reproductive Health

RTI Reproductive Tract Infection

SIDA Swedish International Development Cooperation Agency

SRH Sexual and Reproductive Health

STD Sexual Transmitted Disease

STI Sexually Transmitted Infection

UNAIDS Joint United Nations Programme on HIV/AIDS

UNFPA United Nations Population Fund

USAID United States Agency for International Development

VCT Voluntary Counseling and Testing

YMEP Young Men as Equal Partners

xi ACKNOWLEDGEMENTS

This study is part of a research project on "Assessing the Benefits of Integrated HIV and Reproductive Health Services in Kenya, Swaziland and Malawi" funded by the Bill and Melinda Gates Foundation in collaboration with the International Planned Parenthood Federation (IPPF), the London School of Hygiene and Tropical Medicine and the Population Council.

I would like to give special thanks to Professor Lilani Kumaranayake, academic supervisor, Dalhousie University for giving me the opportunity to be a part of this study and for her support throughout the completion of this thesis. Thank you to Ms. Fern Terris-Prestholt, London School of Hygiene and Tropical Medicine for her time and support throughout the course of this study and to all the Family Health Options Kenya staff who participated in the research, for their help and hospitality.

I also thank Professor Mathieu Dufour and Dr. Barry Lesser for agreeing to be my readers and providing valuable feedback and suggestions. Their contributions have greatly enhanced the quality of this thesis.

Finally I would like to thank my dearest friends, Ifeatu Nwafornso and Ferdinand Mito- Yobo. I couldn't have asked for better classmates. Thank you!

xn CHAPTER 1: INTRODUCTION

Almost thirty years since the discovery of the human immunodeficiency virus (HIV),

HIV/AIDS remains one of the greatest challenges to development in sub-Saharan Africa.

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), sub-

Saharan Africa is the most affected region, with more than 67% of the 33 million people living with HIV worldwide (UNAIDS, 2008). In addition, UNAIDS estimated that by the end of 2007, women accounted for nearly 60% of the new HIV infections in sub-Saharan

Africa. With the pandemic showing no signs of abating, governments have been forced to adopt more aggressive measures to ensure prevention of HIV transmission. Therefore, efforts to stop new HIV infections continue to be as important as providing testing; and treatment to those already living with HIV.

1.1 Background

As HIV prevalence remains high in sub-Saharan Africa, the inclusion of HIV and sexually transmitted infections (STI) counseling, testing and treatment into traditional sexual reproductive health (SRH) services has gained more attention. The high prevalence rates, particularly among females of reproductive age, formed an impetus for the commitment by the international community at the 1994 International Conference on

Population and Development (ICPD) in Cairo, to provide comprehensive reproductive health care services including the management of STIs and HIV (Lush et al. 1999; Dehne et al. 2000). Particular emphasis was placed on controlling new HIV and STI infections through existing maternal and child health (MCH) and family planning services offered at most primary health outlets in developing countries (Lush, 2002). However, despite a

1 commitment to provide more comprehensive reproductive health services, sub-Saharan

African governments have been slow in operationalizing the integration of HIV and STI services into SRH services (Dehne et al. 2000). In countries where integration has been initiated, different models of integration have been piloted. Models of integration range from the addition of voluntary counseling and testing (VCT), STI services into family planning (FP) services; HIV care and treatment into VCT/STI and FP services; HIV services into antenatal care (ANC) and post-natal care (PNC); to integrated FP/VCT/STI services for youth.

Generally, the integration of HIV services such as counseling, testing, care and treatment into family planning, antenatal care, and postnatal care services has been cited as beneficial for reducing HIV incidence and improving women's health, while meeting the reproductive needs of people living with HIV/ AIDS (PLWHA). Pilot projects integrating

VCT and Prevention of Mother to Child Transmission of HIV/AIDS (PMTCT) services into FP and Maternal and Child Health (MCH) services in resource-constrained settings have proven to be reasonably successful in providing testing services to women (Druce et al, 2006). Likewise, the addition of family planning services into HIV settings such as

VCT and PMTCT sites has proven to be beneficial in reaching clients who would otherwise not visit the traditional family planning clinics. Furthermore, the integration of

HIV care and treatment in family planning sites has ensured the continuum of care for

HIV positive persons.

The success of these pilot projects has proven that the strengthening of existing SRH services to incorporate and deliver a range of HIV/STI interventions is feasible and should be explored in a bid to reduce the transmission of HIV.

2 1.2 Economics of Integrating HIV and SRH Services

Since the 1994 ICPD, integration of HIV and SRH services as a strategy to combat the

HIV pandemic has been the mantra among reproductive health experts in many sub-

Saharan African countries. However, while the benefits of integration are incontrovertible, there are still uncertainties regarding the costs and cost effectiveness of integrating HIV and SRH services. Although it has generally been assumed that the integration of HIV and SRH services is more cost effective than the provision of these services separately, a review of the literature (see chapter 3) reveals that the evidence of the economic analysis of such integrated services is scarce. Such economic analysis can be used by policy makers to guide decisions around the delivery of integrated HIV and

SRH services.

One could surmise that the integration of services may result in economies of scope and minimization of transaction costs. Questions on the existence of economies of scope, defined as the lowering of production costs resulting from joint production, can be answered using estimates of a cost function that shows the relationship between costs and output (Weaver & Deolalikar, 2004). Considering the dual relationship between cost functions and production functions, an understanding of the underlying production function therefore forms a crucial basis for costing of such integrated services. However, although key to understanding the cost implications of integration of services, to date very little is known about the production processes of integrated HIV and SRH services.

Therefore, the extent of economic analysis of these integrated services is limited by the gap in knowledge regarding how integrated delivery of HIV and SRH services works.

3 1.3 Aims and Objectives of the Thesis

This thesis is part of a broader research project looking at "Assessing the Benefits of

Integrating HIV services into Sexual Reproductive Health Services in Kenya, Swaziland

and Malawi." As a first step in addressing the dearth of economic analysis of integrated

HIV and SRH services, this thesis aims to provide an understanding of how integration of

HIV and SRH works. More specifically, to address the noted information gap, the goal of

this thesis is to describe the production process of a model of integrated HIV and SRH

service delivery in six Family Health Options Kenya (FHOK)1 operated clinics.

To achieve the goal of this thesis, the following objectives have been identified:

i. provide a summary of the relevant economic theory on integration of health services; ii. provide a review of current literature regarding integration of HIV services and sexual

reproductive health services; iii. provide a background on the HIV status in Kenya and the national response; iv. develop a tool to describe the production process of HIV and SRH services in six

FHOK clinics; v. present the results of an analysis of the production process of integrated HIV/STI and

SRH service delivery in six FHOK clinics; vi. discuss the relevance of these findings and their implications for ongoing discussions

on the benefits of integrating HIV and sexual reproductive health services.

1 Family Health Options Kenya (FHOK) formerly known as the Family Planning Association of Kenya, is a member association of the International Planned Parenthood Federation.

4 The objectives of this thesis are met through the following chapters. Chapter 2 will present the economic theory related to the integration of HIV and SRH services. Chapter

3 provides a literature review, highlighting efforts to integrate HIV into reproductive health services in high HIV prevalence countries in sub-Saharan Africa. Specific background information on Kenya and HIV in Kenya and a discussion of integration of

HIV and STI services with SRH services, as well as the methodology of the study, will be presented in Chapter 4. Chapter 5 will present the results of the analysis of the production process of integrated HIV and STI services with SRH services in six FHOK clinics. This is followed by a discussion and conclusion in Chapter 6. Limitations of this study and policy implications of the study will also be highlighted.

5 CHAPTER 2: CONCEPTUAL APPROACH TO INTEGRATION

The aim of this chapter is to provide an overview of the economic theory underpinning

integration of services. The economic theory constitutes the conceptual framework on

which the remainder of this thesis will be built. The economic theory presented herewith

can be applied to the delivery of integrated HIV and SRH services since the production of

health care services is similar to the production of any other service.

To achieve this aim, the chapter begins with an outline of production theory and

production functions. Key economic concepts relating to integration of the production

process and costs will be reviewed. This will be followed by a discussion of economies of

scope supplemented by transaction cost economics, used to provide a framework for

analyzing integration of services. The final section will provide conclusions.

2.1. Production Theory

Production theory is the basic foundation of the theory of supply. The economic theory of production therefore focuses on the organization and structure of the production process

and provides an understanding of the creation of goods and services available to

consumers. Production is simply defined as the process of transforming inputs into

outputs (Jehle & Reny, 2001). Although production is generally seen as being carried out by private firms, the theoretical structure of production is equally applicable to the production of goods and services by government agencies and nonprofit institutions such

as universities and hospitals (Maurice et al., 1982).

6 Output refers to the final goods or commodities, intermediate products or services as in

the case of health care. Inputs, also referred to as the factors of production, are defined as

the means of producing the goods and services. They can be classified broadly either as

labour, capital (such as machinery and equipment), or land and other natural resources.

Inputs can be classified further into fixed and variable inputs. Fixed inputs are those that

cannot be changed during a certain time period while variable inputs, on the other hand,

are those that can be changed easily on short notice. Many types of labour services and

inputs of raw and processed materials are considered variable inputs (Maurice et al.,

1982).

Whether an input is fixed or variable depends on the length of time being considered.

With respect to the time horizon of production, economists focus on two time periods: the

short run and the long run. The short run is defined as the time period during which at

least one input is fixed. In this case, with the existing equipment, changes in output can

only be accomplished by changing variable inputs such as the number of workers. Jehle

& Reny (2001) note that as the amounts of the variable inputs are changed, the proportions in which fixed and variable inputs are used are also changed. The long run,

on the other hand is defined as the time period during which the quantity of all inputs can be changed.

Another important element in production is the state of technology, which refers to the knowledge regarding how goods and services can be produced from a given amount of resources. Jehle & Reny (2001) note that technology determines and restricts what is possible in combining inputs to produce outputs.

7 Production theory is based upon the assumption that the single most compelling reason for the existence of firms is profit maximization. Therefore production decisions are influenced by the firms' desire to produce a given level of output using the least amount of inputs. Determining the optimal levels of each input can be done through analysis of the production function hence the discussion in the following section.

2.1.1 Production Function

Generally, economists describe production of output as a function of labour (L) and capital (K), such that:

Q=f(KL) [2.1] where Q = quantity of output for any production process; L = number of workers; and K

= equipment and infrastructure.

This technical relationship between inputs and outputs under the assumptions of cost minimization is formally referred to as a production function. Grieve (2006) notes that the production function defines the alternatives and specifies the range of technical possibilities available to producers. Therefore, in addition to depicting the total output a given set of inputs can yield, a production function can also provide information about the degree to which one input can be substituted for another without affecting total output.

8 2.1.2 Production Isoquants

A production isoquant is used to analyze production in the long run, when using more than one variable input in the production process. An isoquant is defined as a curve or locus of points showing all the possible combinations of inputs physically capable of producing a given level of output (Maurice et al. 1982; Mansfield & Yohe, 2004).

Figure 2.1 Isoquant Map

Capital

Isoquants

K0' Kr

U Li Labour

An isoquant map, as depicted in figure 2.1, can be used to illustrate the degree to which one input can be substituted for another while maintaining the same level of output. The slope of an isoquant referred to as the marginal rate of technical substitution (MRTS), depicts this trade-off between inputs. Where two inputs, K and L, are employed in a production process, the marginal rate of technical substitution between inputs K and L denoted as MRTSKL is defined as the ratio of the marginal products of the two inputs.

9 MRT 90TJWK dQ(K,L)/dL

In some production processes it may be possible to substitute one input for another, in which case inputs are perfect substitutes. However, other production processes require inputs to be used in fixed proportions making it effectively impossible to substitute between two inputs (Jehle and Reny, 2001). Such inputs are referred to as perfect complements.

2.2 Costs of Production

The firm's costs of production refer to the expenditures it makes to acquire the inputs required to produce the optimal level of output. If the firm is operating in an environment of perfect competition, and therefore faces fixed input prices, then one way to minimize these costs will be to select the least costly combination of inputs for a given level of output. The firm's long run cost minimization problem is therefore to form an input combination which will minimize the cost of producing a given output (Gravelle & Rees,

1981). The cost function and production function have a dual relationship which implies that with constant prices, the production technology can be derived from the cost function and vice versa.

Based on the assumption that the firm's overriding objective is to maximize profits, the firm will therefore choose that optimal output level and combination of factors that solve the following mathematical problem:

Max n (Q) = P Q f (k, 1) - C (Q) [2.3]

10 The solution to this problem tells us how much output the firm needs to sell and how

much inputs the firm will have to buy to produce the optimal output. Conversely, the

firm's long run cost minimization problem is expressed as

Min C (Q) = rk + wl subject to the production function Q = f (k, 1) [2.4]

In this case, r = price of a unit of capital input, w = the wage on a unit of labour and Q is

the desired output level.

The solution to the cost minimization problem can be analyzed by forming a Lagrange

function

L= rk+ wl + X [Q - f (k, 1)] [2.5]

The first order conditions for the constrained minimization are:

dk dk

— = w = 0 [2.6] dl dl

— = Q-rJc-wl = 0 dX

The optimal cost minimizing input combination will be a function of the prices of the inputs and the output level produced.

l*=f(r,w,Q) [2.7]

k* = f (r,w,Q)

11 Generally, if a production process is both cost minimizing and profit maximizing, then it

is also efficient. As such, efficiency is an important aspect in the production decision.

There are two types of efficiency relevant to the production discussion. These are

economic and technical efficiency.

Technical efficiency is obtained when output is maximized for a given level of inputs, or

when input is minimized for a given amount of output (Retzlaff-Roberts et al., 2004). A

technically efficient production process therefore uses the least amount of inputs to produce the maximum possible output. As such, any point on an isoquant is considered technically efficient. Economic efficiency, on the other hand, refers to the minimization

of cost for the output produced (Gravelle & Rees, 1981). Maurice et al. (1982) note that

economic efficiency takes technical efficiency and prices as given and seeks maximization of output or the minimization of cost under these conditions. Therefore, an input mix for any given output is considered economically efficient if the ratio of the marginal productivity of the inputs equals the ratio of their factor prices. It is worth noting that while economic efficiency implies technical efficiency, technical efficiency does not necessarily imply economic efficiency.

2.3 Joint Production

Traditional economic analysis of the production process has focused mostly on single product firms. However, in reality most firms produce more than one product or service, for example, in health care, where joint production is a common feature. As illustrated in the previous section, producers have to make various production decisions in order to

12 achieve their overarching goal of profit maximization and cost minimization. A multi-

product firm may have the following separate production functions for two outputs.

Qi=f(K,L) [2.8]

Q2 = f(K,L,M)

where Q = quantity of output for any production process; L = number of workers; K =

equipment and infrastructure; and M = technology.

In certain cases, joint production or integration may result in efficiency gains in which

case the firm may opt to combine production as illustrated by:

(Qi,Q2) = f(K,L,M) [2.9]

Using the theory presented thus far, the following sections outline two main cost concepts related to the integration of production and service delivery: economies of scope and transaction costs theory.

2.4 Economies of Scope

One of the determinants of joint production is the potential for economies of scope.

Economies of scope measure the relationship between cost and product mix and therefore refer to the efficiency gains associated with producing various products jointly rather than separately. Mansfield and Yohe (2004), note that economies of scope exist when a single firm or plant can jointly produce two or more products more cheaply than separate firms can. This is illustrated mathematically as:

C(Qi) + C(Q2)>C(Q1,Q2) [2.10]

13 where Qi is the output level of product 1 and Q2 is the output level of product 2.

Economies of scope may occur because the production of various products uses common

production facilities or other inputs (Mansfield & Yohe, 2004; Salvatore, 2003). Bailey

and Friedlaender (1982) note that economies of scope may arise if a given factor or input is imperfectly divisible, so that the production of a small set of goods would leave excess

capacity of utilization of that input.

Whether or not it is more efficient to combine the production of outputs can be

determined using estimates of a cost function, which can be derived from the production function. In a study of economies of scope in Vietnamese hospitals, Weaver and

Deolalikar (2004) illustrate how to test for economies of scope using the Barnum and

Kutzin (1993) equation, presented as:

= [C(ft) + C(Q„)-C(Q)] [2iU] C(Q)

The index shows whether it is cheaper to produce outputs jointly rather than separately.

In this case, if scope is greater than zero, economies of scope exist and it is therefore more efficient to integrate the provision of services. If scope is less than zero it is more efficient to provide services separately.

2.5 Transaction Costs Theory

Another concept that explains a firm's organization of its production processes is the transaction cost theory. Transaction costs were introduced into modern economic analysis by Coase (1960). Transaction costs refer to those costs associated with the transformation

14 of inputs into output (Jamasji-Pavri, 2006). These costs can be ex ante or ex post. Ex ante

costs related to the execution of transactions include search and information costs,

bargaining and decision-making costs, while ex post costs include monitoring and

enforcement costs to ensure compliance by all parties.

According to Coase (1960), transaction costs play an important role in the organization of

a firm. Coase argued that firms emerge to economize on transaction costs of market

exchange and that the extent to which a firm integrates its production processes depends

on the magnitude of these transaction costs. Transaction costs theory therefore

emphasizes the limitations of contractual relationships and the need for flexible means of

coordinating production and delivery of services (Preker et al, 2000). Concurring that

transaction costs determine the nature and evolution of firms and institutions, Williamson

(1981) focused on conditions under which transactions are organized in an integrated manner. He noted that there are two behavioral assumptions on which transaction cost

analysis relies: bounded rationality and opportunism.

Bounded rationality implies that decision-makers cannot process all available information in making decisions owing to limited analytical and data processing capability and incomplete information (Herath, 2005). Herath (2005) notes that bounded rationality contradicts the neoclassical notion, that individuals are rational beings capable of undertaking the necessary computations to achieve utility maximization. Under these conditions of limited information processing capacity, individuals make decisions without considering all possible outcomes and alternatives. As a result, decision-makers replace utility maximizing with satisficing behavior such that rather than seeking to maximize their utility, agents are satisfied with less than optimal outcomes.

15 Satisficing involves pursuing the most satisfying rather than the optimal course of action.

Simon (1959) notes that although economic theory does not consider satisficing

behaviour, the notion of satisficing features prominently in the treatment of motivation in

psychology. According to Simons, psychological studies have shown that search for

alternatives is induced when actual performance falls short of the aspired level while at

the same time expectations are lowered. If aspirations adapt to actual performance, then

satisficing behaviour replaces rational behaviour. In relation to the behaviour of the firm, bounded rationality causes contracting problems, limiting the achievement of complete contracts. Firms therefore compensate for this limitation by organizing their transactions in an integrated hierarchical manner.

Opportunism is another behavioral assumption that further limits complete contracting.

Williamson (1981) defines opportunism as "self-interest with guile." Incomplete information enables parties to a contractual agreement to operate opportunistically by exploiting any information asymmetry.

Another related issue and perhaps most important dimension for describing transactions is asset specificity (Williamson, 1981). Asset specificity refers to the characteristics of assets that determine whether they can be used for other purposes other than what they were originally intended for. Williamson (1981) distinguishes between three types of asset specificity: site specificity, physical asset specificity, and human asset specificity.

Generally, assets that are unspecialized among users can easily be turned to other uses without significant cost consequences.

16 Bounded rationality, opportunism, and asset specificity all raise the costs of executing

transactions. These costs include ex ante search costs to reduce adverse selection an ex

post monitoring and enforcement costs to reduce moral hazard problems (Herath, 2005).

Coase (1937) notes that it is against these odds that firms evaluate the relative costs of

alternative governance structures for managing transactions such as spot market

transactions, short term contracts, long-term contracts, and vertical integration.

2.5.1 Application of Transaction Costs Theory to Integration

Transaction cost economics provides a framework for examining why firms integrate their production processes (Levy, 1985). Economic theory distinguishes between two types of integration, namely, vertical and horizontal integration. Sobczak (2002) defines vertical integration as the creation of complex systems linking resources, the production process, and the provision and distribution of services. Vertical integration is typified by one firm engaging in different aspects of production. For example, a firm may be engaged in growing raw materials, manufacturing, transporting, marketing, and retailing the final product.

The theoretical rationale for vertical integration is the lowering of production costs through shared fixed inputs and minimization of transaction costs. Transaction cost savings focus on overcoming information asymmetries and contractual incompleteness.

Therefore, against these information limitations, vertical integration not only minimizes transaction costs by eliminating contracting and monitoring costs but also results in improved coordination among different partners. In health care settings, this ensures that continuity of care is achieved.

17 Apart from the efficiency and effectiveness determinants, there are other motivations for vertical integration. These include: overcoming market imperfections such as regulatory constraints and monopoly power; responding to internal organization factors, and to environmental changes that affect market conditions, production technologies, and transactional relationships (Conrad and Dowling, 1990).

Horizontal integration refers to the concentration of many individual enterprises offering similar services into one production and service provision system. While vertical integration is more common in production processes, horizontal integration is more common in marketing processes. Horizontal integration usually involves interrelationships between or among two or more production entities.

Mick et al (1993) note that horizontal integration ranges from group purchasing agreements to complete integration of services and facilities as in the case of a merger.

Group purchasing agreements, the simplest form of integration, seeks to reduce costs through bulk purchasing, competitive bidding, and contract negotiations for supplies and services. Mergers, on the other hand, which result in the complete amalgamation of two separate entities, are motivated by possibilities of economies of scale, concentration of management talent, strengthening of a firm's financial position, hence increased access to the capital markets, and reduction of redundant services and personnel (Mick et al.,

1993). Regardless of the level of integration, horizontal integration is aimed at minimizing transaction costs either through information sharing at the very least or combined use of assets and facilities. Therefore, as with vertical integration, the objective of horizontal integration is the enhancement of efficiency resulting in economic gains.

18 2.6 Conclusion

The objective of this chapter was to provide an overview of the link between economic theory and the firm's production decisions. Most importantly, the chapter provides an understanding of why firms integrate their production processes. Generally, the firm is faced with making choices to determine the optimal level of outputs, where costs are minimized and output is maximized. An understanding of the underlying production function and processes in any production is therefore important in determining the optimal output levels.

Transaction costs theory sheds light on the conditions under which it is better for firms to integrate production processes within the same organization rather than interacting with other suppliers in the market. Governance arrangements are therefore evaluated by comparing the costs associated with planning, executing and monitoring production and market exchanges.

The theories of economies of scope and transaction cost analysis focus on the question of efficiency. Therefore, it is in the interest of efficiency gains that firms integrate their production and service delivery processes to lower their production costs and minimize transaction costs. The application of these economic theories to the production of HIV and SRH services can provide an economics lens to a health topic, through which decision-makers can determine optimal level of services with a given level of resources.

The next chapter presents a literature review of integration of HIV and SRH services. An introduction to the integration of health services and in particular a discussion of what is and what is not known about integration of HIV and SRH services will be presented.

19 CHAPTER 3: LITERATURE REVIEW

The aim of this thesis as stated in chapter 1 is to provide an understanding of the production process of integrated HIV and SRH services. Before undertaking an analysis of the production processes of these integrated services, it is necessary to develop an understanding of the background, rationale, and relevant considerations for such integration.

This chapter therefore aims to provide a definition of integration; an introduction to the concept of integration of health services; a review of the relevant literature regarding integration of HIV and SRH services; a description of the features of various models of

HIV and SRH services integration as well as the challenges of integration. Key findings with regard to how resources are combined to produce integrated services will also be presented. The results of this literature review will help situate this study in the broader context of integrated service delivery and highlight the gap in the literature to which this research is intended to contribute.

3.1. Defining Integration

According to the United Nations Population Fund (UNFPA) and IPPF, service integration refers to, "incorporating aspects of two or more types of services as a single coordinated and combined service" (UNFPA & IPPF 2004). In the health sector, integration has been defined as offering two or more services at the same facility during the same operating hours, with the service provider actively encouraging clients to use the other services in the same facility during the same visit (Foreit et al., 2002). Sobczak (2002) points out that from the health care providers' point of view, integration is oriented towards patients'

20 needs. In this case, the service providers' main interests are easy access to health care services and continuity of care, the best possible results of treatment, quick clinical information flow, and patient satisfaction. In the economics context, as defined in chapter

2, integration is viewed as a means to achieve competitive advantage and economic gains by lowering production costs and minimizing transaction costs.

Generally, a lack of consensus on what integration in the HIV/SRH context entails has been cited (Kisubi et al, 1997; Dehne et al. 2000; Lush, 2002). Kisubi et al (1997) suggest that integration at its simplest form refers to service providers responding to an increased array of clients' reproductive health needs on their own initiative. In the extreme case, integration may involve the training of service providers in counseling and clinical care of STI infections including HIV (Kisubi et al. 1997).

Although there appears to be a lack of agreement on what is meant by having integrated services, there is consensus on the desired outcomes of health care integration. These are: increase in health service provision efficiency; cost control; and an increase in the quality of service provision, hence improved health outcomes and patient satisfaction (Sobczak,

2002).

3.2. Forms of Integration

While the economic literature distinguishes between two types of integration namely vertical and horizontal integration, the health care literature includes a third form of integration, diagonal integration. In addition, with reference to vertical and horizontal integration, we can further distinguish between structural and functional integration.

Table 3.1 provides a summary of the different definitions of integration.

21 Table 3.1 Definitions of Integration

Type of Integration Definition

Vertical integration The coordination of service lines that are at different stages of production. For example, an acute care hospital can provide ambulatory care, long term care, or home care (Conrad & Dowling, 1990).

Horizontal integration Involves any new interrelationship between or among two or more health care facilities (Mick et al. 1993).

Diagonal integration Stresses the importance of integration and coordination of vertical and horizontal health care interventions (Sepulveda et al, 2006).

Structural integration Provision of comprehensive services under one roof or the same facility but through specialized units such as a MCH clinic, FP clinic, STI clinic, and VCT Centre and by different service providers. (Kisubi et al. 1997).

Functional integration Provision of comprehensive services such as MCH/FP/STl/HrV by a single provider adequately trained to address all client needs during the same visit (Kisubi et al. 1997).

3.2.1 Vertical Integration

In line with economic theory, Brown and McCool (1992), as cited by Sobczak (2002), define vertical integration from the health sector perspective as "the ability of one provider system to provide all levels and intensities of service to patients and health care consumers from a geographically contiguous region when these clients present themselves to that system" (p. 2). Vertical integration therefore allows for the provision of a broad range of patient care and support services such as HIV testing, ANC, PNC, child welfare services and FP, home-based care, in one health care facility. Conrad and

Dowling (1990) provide an example of vertical integration where an acute care hospital

22 acquires or establishes different levels or types of care such as ambulatory care and long- term care.

3.2.2 Horizontal Integration

Horizontal integration, on the other hand, refers to the concentration of many individual enterprises into one production or service provision system. Sobczak (2002) defines horizontal integration as "the enlargement of size and scope of a sector through acquisition of other forms of cooperation with the providers offering similar kind and range of services" (p. 2). Horizontal integration ranges from complete integration of services and facilities through health facility mergers and consolidations to voluntary health planning councils and group purchasing agreements (Mick et al. 1993). Horizontal integration in the health care setting would be exemplified by the merger of two health facilities offering similar services with the objective of increasing the number of services provided.

3.2.3 Diagonal Integration

A more recent approach to integration of health care services is the diagonal approach. In a study of the improvement of child survival in Mexico, Sepulveda et al. (2006) define diagonal integration as "the proactive, supply-driven provision of a set of highly cost- effective interventions on a large scale bridging heath clinics and homes" (p. 2020). The diagonal approach therefore stresses the importance of integration and coordination between vertical and horizontal interventions. In the case of Mexico, the diagonal approach included incremental integration of a series of vertical interventions, namely the

23 provision of oral rehydration salts, universal vaccination programme and a clean water programme, to reduce child mortality resulting from diarrhea.

3.2.4 Structural Integration

Sobczak (2002) defines structural integration as the creation of one big complex organization consisting of many different parts, able to perform various tasks. In the health service setting, structural integration may be illustrated by the provision of comprehensive services under one roof or the same facility but through specialized units such as MCH clinic, FP clinic, STI clinic, and VCT Centre and by different service providers (Kisubi et al., 1997). Figure 3.1 illustrates the concept of structural integration which is akin to the concept of "one stop shopping."

Figure 3.1 Structural Integration

One provider, One provider, referred to Referred to a different -• different sessions within -• provider within the one session one building same building

One Stop Shop = the provision of services "under one roof"

Good collaborative links and referral Providers and services pathways between working in isolation

Source: French et al (2006)

24 A classic example of structural integration is where one nurse only provides family planning counseling and refers the client to another service provider in the same facility for another service such as HIV counseling. However, structural integration may also be achieved by using referral systems where a client is referred to another facility for a service.

3.2.5 Functional Integration

Like structural integration, functional integration also entails coordination of health care activities and functions within a single complex organization. However, unlike structural integration, one adequately trained service provider is able to provide multiple services to a client during the same visit. Functional integration in the HIV and SRH context refers to an arrangement where both FP and HIV services, such as counselling and testing, are available and offered by the same provider during the same visit.

3.3. History of Integration of Health Care Services

The concept of integration of health services was not unique to the 1994 International

Conference on Population and Development (ICPD). Prior to the ICPD, the 1978

Declaration of Alma Ata had committed to "health for all people by the year 2000" and a key strategy to achieving this goal was the delivery of integrated services through a comprehensive primary health care approach (Lush et al., 1999; De Pinho et al., 2005).

De Pinho et al. note that this approach was in response to the failure of the World Health

Organization's (WHO) vertical approach to the malaria eradication campaign and the increasingly high infant and maternal mortality rates in developing countries. The

25 integration of services during this period was driven by a desire for equity for all in

access to health services.

However in the early 1980s, as developing countries were faced with declining

commodity prices coupled with the oil crisis, governments were forced to decrease

spending on social services including health care. As a result, comprehensive integration

of services was ignored as a priority and the focus shifted to funding for vertical programmes. De Pinho et al (2005) note that vertical programs were regarded as a key factor in promoting national economic development in poor countries.

Renewed interest in integration of services emerged again in the 1990s with the introduction of the World-Bank-led health sector reform. The health sector reforms formed part of the neo-liberal package implemented by the Bretton Woods institutions in developing countries, which included changes in financing, decentralization and increasing the role of the private sector. De Pinho et al. (2005) note that while integration of services was not explicitly mentioned as a key element of the health sector reform, many of the World Bank-supported health and social programs included an integration of health services. This project strategy was viewed as a cost-effective strategy and a solution to improving efficiency and service delivery (De Pinho et. al., 2005)

The extremely rapid rise in HIV prevalence in the 1990s coupled with the high STI incidence in many sub-Saharan African countries heightened international concerns about the relative lack of services to address these problems (Lush, 2002). To address these problems, the international community, at the 1994 ICPD in Cairo, committed to providing a comprehensive and integrated set of reproductive health services for women,

26 men and adolescents (UNFPA, 1995). The recommendations of the ICPD emphasized shifting the agenda from controlling fertility to ensuring that women were able to achieve personal reproductive goals safely and effectively (Lush, 2002).

At the ICPD, considerable attention was paid to the best way to provide reproductive health services. Particular emphasis was placed on integrating previously vertical sexual reproductive health services with specific attention paid to HIV and STIs (Lush et al.,

1999). Essentially, women would be able to receive care for a range of problems during one visit to a health facility. The integration of HIV and STI services into existing primary health services namely family planning and maternal and child health programs, was thus advocated with a view of controlling the rapid spread of HIV and improving women's overall reproductive health.

3.4 Rationale for Integrating HIV and SRH Services

Integration of HIV/STI services and SRH has been endorsed as an effective way to maximize limited health care resources (Creanga et al., 2007). In addition to increasing operational efficiency; several other reasons have been proposed to explain why it is important to integrate HIV and STI services into SRH services in high HIV seroprevalence settings. First, it has been argued that SRH services can make a significant contribution to the prevention of HIV through provision of information and counseling on the HIV risk reduction strategies, education on STIs, as well as promotion of dual protection through provision of female and male condoms (Askew & Berer, 2003;

Berer, 2004). Askew and Berer (2003) note that one of the main reasons why integration of HIV and SRH services has the potential to contribute to the prevention of HIV

27 transmission is that both men and women seeking SRH services would be receptive to

HIV information and services when they understand the importance of preventing and managing HIV infection through the use of family planning, dual protection, safe antenatal an delivery care, and STI prevention and treatment.

Second, since the majority of HIV cases are transmitted sexually or from mother to child,

Askew & Berer, 2003 note that it is only through antenatal, delivery and post-natal services that interventions for preventing perinatal and breastfeeding-related HIV transmission can be offered. Therefore, HIV services are important for clients seeking family planning and antenatal care services. Conversely, as HIV and AIDS have profound effects on sexual and reproductive health, SRH services are crucial for HIV- positive men and women (Berer, 2004). The most significant impact of HIV on women's reproductive health is on fertility and reproduction. In sub-Saharan Africa where HIV affects women of reproductive age disproportionately, family planning services offered to

HIV-positive women can help reduce new HIV infections by decreasing unintended pregnancies and hence preventing vertical HIV transmissions. It is worth noting that

HIV-positive women risk not only infecting their infants but have a higher risk of stillbirths, low birth weight and premature births (Duerr et al., 2005). As such, Duerr et al. (2005) note that providing contraceptives for HIV-positive women can be as effective at decreasing HIV infection in infants and other related complications, as providing antiretroviral treatment to HIV-infected women.

Third, the stigma associated with HTV and STIs may prevent certain clients from visiting stand-alone HTV and STI clinics. Therefore integration of the four components of reproductive health, family planning, maternal and child health, management of STIs and

28 adolescent reproductive health, may decrease stigmatization of such clients (Budiharsana,

2002).

Fourth, as French et al. (2006) point out, it has been argued that integration of services under one roof may be more successful at targeting clients who are not aware they need the alternative service. Married women have traditionally been characterized as a "low risk" group in terms of sexual transmission of HIV, however, in generalized epidemics, the risk of infection among married women increases (Askew and Berer, 2003). This indicates the importance of integrating HIV and SRH services to ensure clients have access to HIV services.

While a majority of studies citied in this thesis advocate the integration of HIV and STI services and SRH services, various arguments against integration of these services have been put forth. The first of these is that since conventional programs providing family planning and MCH services have been predominantly targeted at women, it is unlikely that they attract sexually active adolescents and men who are at a high risk of HIV infection (Askew and Maggwa, 2002; Foreit et al., 2002). As such, Caldwell & Caldwell

(2002) emphasize that the "central problem is that family planning and HIV/AIDS services serve two different constituents" (p. 112).

Apart from perceived differences in target audiences, other arguments against integrating

HIV and STI services and sexual reproductive health services include operational incompatibilities such as inadequate space, lack of appropriate equipment, health provider attitudinal barriers, and resource constraints (Kisubi et al., 97; Foreit et al., 2002;

Bradley et al., 2008).

29 3.5 Organization of HIV and SRH Services

Before we look at the organization of HIV and SRH services, it is important to understand what services are included in the definition of sexual and reproductive health

services. Figure 3.2 provides an illustration of the various components of SRH and HIV

services.

Figure 3.2 Components of HIV and Sexual Reproductive Health Services

Components of HIV Services Components of SRH Services

HIV/STI Services include FP Services include • Information, education and counseling • Counseling • Condom promotion and distribution • Provision of a range of FP methods • STI syndromic management and • Follow up and management of side- diagnostic treatment effects and complications • HIV pre-and post-test counseling • Screening for STIs and syndromic management of STIs. • Antiretroviral treatment * Home based care \ y N MCH Services include • Antenatal care • Postnatal care • Immunization • Growth monitoring

Source: Kisubi, Farmer & Sturgis (1997).

Askew and Berer (2003) note there are a number of priorities addressed under sexual and reproductive health. These are: "ensuring contraceptive choice and safety, improving maternal and newborn health, reducing sexually transmitted and other reproductive tract

30 infections, and HIV/AIDS, eliminating unsafe abortion, prevention and treatment of

infertility, screening and treatment for reproductive tract cancers and treatment of

menstrual disorders" (p. 52).

In many developing countries, HIV and sexual reproductive health services have

historically been offered separately. This is attributed to the fact that historically, many of

the sexual reproductive health services have been predominantly targeted at women of

reproductive age, while HIV services have been targeted at specific high-risk groups.

However, since the ICPD, many sub-Saharan African countries have moved to

integrating service delivery although the patterns of integration vary considerably.

While in some settings it is possible to provide family planning, maternal health and child

services as well as HIV/STI services at the same site, in others, where comprehensive

service provision is not feasible, referral linkages for HIV and STI services have been

incorporated into existing family planning and maternal and child health services (Lush,

2002). These variations in the level of integration largely reflect the differences in the

range and type of specific elements of HIV and STI services added to existing family

planning and maternal and child health services or vice versa (Dehne et al., 2000). Kisubi

et al (1997) therefore suggest that integration is best viewed as a process evolving along a

continuum with health care providers at different levels of integration. The simplest form

of integration of HIV and reproductive health services may include the addition of

information and education materials, counseling and testing for STIs and HIV/AIDS and

condom provision to family planning and maternal health services clients. At the other

end of the spectrum, integration involves the incorporation of activities to prevent and manage HIV and STIs into FP and MCH programs (Kisubi et al. 1997). Dehne et al.

31 (2000) note that generally, HIV/STI prevention tasks such as information, education and communication, counseling, and condom promotion have been integrated into family planning services more frequently than care tasks such as laboratory screening, clinical diagnosis and treatment or referral for treatment and care.

3.6 Models of Integrated HIV and SRH Services

This thesis identifies four main models of integration of HIV and SRH services in developing countries. These are HIV/STI services integrated into family planning, antenatal care and post-natal care services; family planning services integrated into VCT and PMTCT settings; family planning services integrated into HIV care and treatment; and integration of HIV/STI into SRH services for youth.

Generally, integration of services transforms the production functions and processes of service delivery. Therefore each model of integrated service delivery implies a difference in the combination of resources hence different production processes. Descriptions of these four models of integration are provided below.

3.6.1 HIV/STI into Family Planning /SRH Settings

Integration of HIV and STI services into existing family planning services is the most common model of integration in sub-Saharan Africa. Dehne et al (2000), point out that in a majority of the cases reviewed, family planning services form the pre-existing infrastructure into which STI management was being integrated. Where services are currently being integrated, some HIV services which may include diagnosis and

32 treatment of STIs, sexual risk-reduction counseling, condom promotion, and HIV voluntary counseling and testing are provided through family planning programs.

Potential benefits of this model have been identified as increased knowledge of HIV prevention strategies among women of reproductive age who are at high HIV risk but might not otherwise receive HIV counseling and information (Shears, 2004). Best (2004) notes that integrating HIV counseling and VCT into antenatal care (ANC) services usually referred to as PMTCT helps prevent infection among pregnant uninfected women. Conversely, it can also identify pregnant women who are HIV infected.

In terms of the production process, since family planning, ante natal and post natal care services are usually provided by the nurse, the inclusion of the provision of HIV testing during family planning, antenatal or post natal care visits implies a training requirement for the nurse to be able to provide HIV testing. In most cases, where nurses are not trained to provide HIV testing, another service provider usually provides HIV testing.

Therefore integration of these services results in the increase in labour inputs.

3.6.2 Family Planning into VCT and PMTCT Services

Integration of family planning services into HIV services is characterized by a range of client-provider interactions that incorporate fertility management within the context of

HIV services (Farrell, 2007). Farrell (2007) notes that these would include provision of

FP information, counseling, risk assessment, and behaviour change communications for informed decision making; health monitoring and treatment procedures that may include referral and provision of medications and/or FP commodities.

33 Counseling and testing services offer a prime opportunity for the integration of

HIV/AIDS and reproductive health services. Voluntary counseling and testing (VCT) centers attract clients who may not normally visit a family planning clinic such as the youth and men. VCT centers therefore provide an opportunity to reach more clients with family planning counseling and provide HIV-positive clients with the help they need to avoid unintended pregnancies and adopt dual protection for prevention of pregnancies and HIV and other STI infections (FHI, 2004). Additionally, providing family planning services at counseling and testing facilities enables providers to offer more targeted family planning counseling because clients know their HIV status.

Duerr et al. (2005) note that integration of family planning and prevention of mother to child transmission of HIV offers an opportunity to integrate family planning services more broadly into antenatal care. Since many women do not return for post-natal care, an emphasis on family planning to HIV positive clients during the antenatal care period creates an opportunity to promote the use of contraceptive use in the immediate post partum period.

In settings with VCT centers, voluntary testing and counseling is usually provided by a lay VCT counselor with no medical training. In most cases the VCT counselor is not trained in family planning provision, in which case while the lay counselor may be able to provide basic FP counseling and contraceptive pills, a nurse trained in FP is required for other FP method provision. On the other hand, PMTCT settings are usually staffed by nurses, most likely trained in family planning and therefore able to provide both FP and

HIV testing services. Therefore, similar to the integration of HIV into FP, ANC and PNC services, the integration of FP into VCT and PMTCT settings affect the production

34 processes in a clinic by increasing the amount of labour input required to provide a service.

3.6.3 Family Planning into HIV Care and Treatment

Unlike the other two models of integration of HIV and reproductive health services, little research has been done on models that integrate family planning into HIV care and support services for PLWHA. However, this model is becoming increasing common in many sub-Saharan African countries.

In this model, family planning services are usually provided by community-based health workers, who are increasingly engaged in outreach and education and provision of health services such as maternal and child health, family planning and HIV/AIDS (Creanga et al., 2007). Community health workers provide home-based care services and are able to provide non surgical contraceptive methods, such as female and male condoms.

The integration of family planning services into home based care shifts family planning service provision from the nurses to the community health worker. This affects the clinics production processes as the community health workers provide most of the services required.

3.6.4 HIV/STI into Youth SRH Services

According to UNAIDS, an estimated 10 million young people aged between 15 and 24 are living with HIV/AIDS and account for about 45% of the new HIV infections worldwide (UNAIDS, 2008). The high HIV infections among youth, coupled with the stigma associated with young unmarried women seeking family planning and HIV/STI

35 services from traditional clinics underscores the need for integrated SRH/FP and

HIV/AIDS services for youth (Kane & Colton, 2005).

In an attempt to address the issues of lack of information and education on risk reduction, the integration of HIV/STI into youth services focuses on the inclusion of various interventions targeted at providing behavior change communication, peer education programs focusing on information, life skills, provision of non-surgical FP methods, and referrals to youth SRH facilities. This integration of HIV and STI services into SRH services for youth impacts the production process of services provided to youth by necessitating the availability of a doctor, clinical officer or nurse to provide clinical services including STI and opportunistic infections treatment as well as family planning services to youths accessing services in the youth centres.

3.7 Challenges to Integration

Although the case for the linkage between HIV prevention, treatment and care and SRH services has been established, the integration of HIV and SRH services has not been easily adopted as a means to curb the spread of HIV (Berer, 2004). Integration efforts have faced a number of challenges. Berer (2004) notes that the most significant barrier to the implementation of integration, has been a lack of sustained and visible leadership on linking the HIV and SRH issues at all levels. In addition; the existence of separate donor departments and funding programs for HIV and SRH has encouraged vertical service delivery (Berer, 2004).

Nationally, although there is an awareness of the importance of integration, responsibility for programmes, budgeting and funding for SRH and HIV/AIDS remain under separate

36 departments supported by different technical agencies (Druce et al. 2006). In a review of

Pathfinder International's experience in the integration of SRH and HIV/AIDS services,

Kane and Colton (2005) identify the tendency of funding mechanisms to support vertical

SRH and HIV/AIDS programs as limiting to the mandate and resources of the implementing agencies at the local level.

Other challenges to integration identified in the literature include a lack of adequate legislative framework for ensuring that integrated provision of services is feasible (Lush,

2002) and a lack of clear technical guidelines for training staff (Lush, 2002). Kane &

Colton (2005) also identify a lack of integrated pre-service and in-service training curricula. Integration is further inhibited by poor health facility infrastructures to offer comprehensive and integrated service delivery, national level stock-outs or shortages of commodities such as HIV test kits and FP supplies.

3.8 Results of Integration Studies

The literature review identified 23 studies on integration of HIV and SRH services which included 15 countries and 10 services ranging from integration of sexuality counseling, provision of condoms, VCT, PMTCT, provision of ART, home-based care, screening for

STIs and treatment of STIs and opportunistic infections into family planning and maternal and child health services. The results of the studies are summarized in table 3.2.

37 Table 3.2 Summary of Integration Studies

Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods 1. Integration of HIV/STI into FP/SRH Settings Abdel-Tawab, 2005. Reproductive Integration of sexual Determine acceptability Sexuality counseling The study results Health health/sexuality issues of including sexuality acceptable to clients despite suggest a positive Egypt counseling into FP issues in FP in Egypt. conservative setting. impact of the sexuality Counseling. training course on Study conducted in six Increased counseling about providers' attitudes family planning clinics the impact of chosen FP towards barrier methods. selected from MOH and method. Study also suggest a Population and Clinical positive association Services Improvement Positive association between training Project clinics. between training providers providers on sexuality- on sexuality-related related counselling and counseling and client client acceptance of acceptance of barrier barrier methods. methods.

Adeokun et al., 2002 Reproductive Counseling on dual Effects of incorporating Increase in discussion of Integrating dual- Health protection and provision of HIV and STI prevention sexual behavior of clients protection counseling Nigeria female condoms in six into family planning and their partners and the and female condom family planning clinics. service delivery through ability of various provision into family the promotion of dual- contraceptives against HIV planning services is protection counseling. infections and how to feasible. negotiate condom use. The attitudes and behaviours of clients Increase in condom male partners are as purchases mainly as a result important as the of acceptance of the female providers and clients in condom. transforming FP services to dual - protection services. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods Bradley et al. 2008 Reproductive Integration of HIV services To examine associations Younger, single men and The study suggests that Health into FP services. between HIV and family older married women most client types may be Ethiopia planning service likely to self-initiate HIV differentially attracted to integration modality and testing. Compared with these facilities three outcomes: VCT facilities offering co- depending on service client composition, located services those integration modality and client-initiated HIV integrating services at room other facility level testing and client HIV and counselor levels were characteristics. status, from VCT client more likely to serve clients records, using multi­ initiating HIV testing. level logistic regression models.

Colton, 2005 Reproductive Integrating HIV into SRH The goal of the PMTCT Significant increase in new PMTCT has become a Health Settings. project is to contribute ANC clients and use of normal service for Kenya to the reduction of PMTCT services. pregnant women Integration of VCT, ART MTCTofHIVinthe Increase in women resulting in a decrease in and PMTCT provision into three target provinces. accepting HIV counseling stigma. SRH and MCH services. and testing. Increased Nevirapine uptake for mothers and babies. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods Dehne et al, 2000 Reproductive Integrating HIV/STI into Review of concrete Some STI/FP integration STI prevention tasks Health SRH Settings experiences with efforts appear to have been such as education for integrated services. beneficial. Less clear is risk reduction and whether STI prevention counseling have been Literature review and when concentrated among integrated into family interviews with key traditional FP clients is planning services more informants working having a positive impact on frequently than the tasks internationally in FP and STI risky behaviours or of STI diagnosis and STI prevention and care. condom use. treatment.

The current state of evidence on the benefits and costs of integration calls for a more O systematic appraisal.

More rigid evaluations of the integration into FP services of both individual STI tasks such as partner notification, different types of counseling, syphilis screening and HIV testing and defined sets of STI activities, as well as costing studies of STI/FP integration must be undertaken. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods Dehne & Snow, Reproductive Integration of STI What elements of STI Improved quality of Integration seems to 1999. Health management into FP management are services, providers' have enhanced quality services provided within the attitudes and of FP services however Desk review of context of integrated communication skills. there is not much documented RH services? What evidence of impact on experiences. evidence is there that Increased access and STI morbidity and no integrating services utilization of services due firm evidence of expands the coverage of to expanded coverage and increased STI care STIs? outreach to men, youth and utilization. Does integration serve other groups formerly not the needs of those at risk targeted by FP services. of STIs but not currently using FP? Do integrated RH services imply modifications in standard contraceptive prescribing practices in areas of high prevalence of STIs? Do integrated RH services increase the chances that those at risk of STIs but not currently using contraceptives may become users? Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods FHI, 2004 Reproductive Integration of HIV services VCT guidelines and High uptake of VCT (13% Overall clients have Health into FP/SRH. informational materials, of clients). been happy to find Cambodia media campaign and everything they need in Integration of HIV hotline about HIV. Overall increase in clients, one place. counseling and testing 13% of whom are males services into existing FP, accessing STI services. ANC and STI/RTI treatment package.

FHI, 2004 Reproductive Integration of HIV into SRH Effects of expanded Study showed that Anecdotal evidence Health settings. service delivery. significant improvement in suggests that trained Zimbabwe all areas related to CBD workers and depot Information about HIV/AIDS/STIs education, holders embrace the HIV/AIDS, STIs, VCT and testing and referrals. provision of information referrals for VCT, PMTCT beyond family planning. services were integrated in Increase in use of male and the role of community based female condoms and distributors (CBD) of referrals to VCT centers. contraceptives.

Fitzgerald et al., Reproductive STI services integrated into Is decentralization of The rate of congenital The study shows that a 2003. Health antenatal care prenatal screening syphilis in the 3 years decentralization strategy effective? following decentralization, is feasible in a remote Haiti Syphilis screening added as 137 cases per rural area with very a component of antenatal 100000 live births, was limited infrastructure. care services significantly lower than before. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods Frontiers, 2000 Reproductive Integration of HIV/AIDS Integration was acceptable Targeted outreach Health into FP/SRH. to both men and women. strategy was Bangladesh instrumental in Addition of RH services for Addition of services for increasing both men at rural health and men led to significantly women's and men's use Family Welfare Centres increased utilization of of STI and general traditionally targeted for clinical services by both health services. women. men and women. Gillespie et al., Reproductive Integration of HIV into The primary objective of A higher proportion of Analysis supports the 2007 Health FP/SRH services. the study is to compare males reported planning to desirability of having changes in the use a contraceptive method VCT services integrated Ethiopia Voluntary HIV counseling knowledge, attitudes and in the future after the into family planning and testing integrated with practices surrounding counseling session. services contraceptive services family planning and risk (VICS). behavior associated with This desire for no more HIV infection among children increased clients who attended significantly for both men VCT clinics with and and women after they were without an enhanced tested HIV positive. family planning component. Horizon, 2002. Reproductive Integration of HIV into SRH Increased awareness about Study demonstrated that Health settings. HIV and PMTCT, infant providing VCT and Zambia feeding and VCT among infant feeding Integrating infant feeding MCH clients. Increased counseling to mothers counseling and VCT into referral links in the attending MCH clinics maternal and child health community. Although there are vital components of care (MCH) services. is increased awareness any mother-to-child about VCT, uptake of VCT transmission reduction services remains low. strategy, whether ARVs More emphasis on are available or not. communication about risk reduction is required in the community. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods IPPF, 2005 Reproductive Integration of HIV care and Increasing access for HIV/AIDS should be Health treatment into SRH settings. PLWHA to another service in the Dominican Republic comprehensive services package of SRH for managing and services offered, rather treating HIV/AIDS than converting a clinic through two clinics in into an HIV/AIDS the Dominican centre. Republic. IPPF, 2005 Reproductive Integration of HIV services Project aimed at Increased access to VCT Although more clients Health into SRH settings. increasing access to and services. are accessing HIV Kenya use of HIV/AIDS care services, FHOK Integration of HIV care and and support for Pregnant women who involvement in delivery treatment into SRH settings. PLWHAs through tested positive received of HIV services not increased capacity Nevirapine based treatment. perceived well by other within FHOK to deliver vertical service HIV/AIDS services. 25 HIV positive persons providers. started on ART. IPPF, 2005 Reproductive Integration of HIV/STI into Project aimed at Number of clients Health SRH settings. strengthening capacity accessing clinics doubled. Rwanda to deliver HIV/AIDS Integrating HIV/AIDS care services including ART Increased demand for VCT into existing SRH services and OIs treatment. and other services. which include already existing VCT services. Education, care and support Clinics do not provide activities were significantly ARTs directly but refer scaled up. clients to Government facilities that provide free services. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods 2. Integration of FP into VCT/PMTCT Settings Asiimwe & Hardee, Reproductive Integration of FP into HIV PLWHA reported a desire to Formal referral systems 2005. Health (VCT, PMTCT, ART) receive FP at the same place remain weak or non­ settings. they are receiving HIV- existent and Uganda related services and from coordination is In two VCT sites, FP is service providers they problematic because of offered as an integral already know. vertical management of component of service. FP/SRH, VCT and Reported increased demand PMTCT programs. In PMTCT sites FP for FP over time. information and non­ surgical contraceptives are A third of FP clients using offered as routine dual methods of protection. component of ANC/PNC services. Bunnell, 2006 Reproductive Integration of HIV Assess the changes in 70 % reduction in risky Providing ART, Health prevention into VCT and risky behaviour and sexual behaviour six months prevention counseling, Uganda treatment settings. estimated HIV after initiating ART. and partner VCT was transmission from HIV- associated with reduced Home-based ART infected adults after 6 Estimated risk of HIV sexual risk behaviour programme that included months of ART. transmission from cohort and estimated risk of prevention counseling members declined by 98%. HIV transmission.

FHI, 2004 Reproductive Integration of FP into HIV Does integration of Low uptake of FP services. The study shows no Health services. other services in a VCT evidence to indicate that Zimbabwe setting increase the providing other services Integrated FP services into a uptake of VCT increases uptake of VCT well-established centre services? services. offering high quality VCT services. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods 3. Integration of Family Planning into HIV care and treatment Nierengarten, 2003 Reproductive Integration of SRH into HIV Feasibility of prevention Mortality, hospitalizations Testing and treatment in Health care, support, and treatment and treatment of and OIs reduced. primary health care Haiti programs. HIV/AIDS programs in Increase in the detection of eliminates stigma resource poor settings. HIV cases and uptake of attached to free standing Integration of free HIV care VCT. AIDS clinic. and treatment with Increase in visits for all prevention. services. Peck et al. 2003 Reproductive Integration of SRH services Examine the feasibility, The number of new people Study demonstrates the Health into HIV/AIDS care, the demand, and the seeking VCT services feasibility, effectiveness Haiti support, and treatment effect of integrating on- increased with an increase and demand of VCT and programs. site primary care in the % of women, reproductive health services into VCT adolescents, and self- services. VCT serves as Integration of on-site services. referred clients seeking an appropriate entry primary care services into AIDS care, TB treatment, point into primary health VCT at a stand-alone VCT Retrospective review of STI management, and care services. centre. Primary care patient records, to family planning. services included HIV and describe the integration TB care, treatment of STIs, of primary care services. HIV transmission rates and SRH. were lower than expected in the setting. 4. Integration of HIV/STI Services and Youth SRH Services Obasi et al., 2006 Reproductive Integration of HIV services Adolescent sexual and Improved SRH knowledge Intervention may need Health into SRH services for reproductive health and reported improvement more time to provide Tanzania Youth. intervention in Mwanza in sexual attitudes. visible impact on Region, Tanzania. biological outcomes IEC and youth friendly Significant increase in (HIV and other STIS, services for SRH/FP/STIs condom use and reduction and pregnancy). and HIV prevention. in number of sexual partners. Additional intervention may be needed. Study Authors/ Scope Integration Model Objectives/ Evidence of Effectiveness Discussion & Country /Integration Strategies Research Conclusions Implemented Question/Methods Pathfinder Reproductive Integration of HIV/STI into The project aimed at Increased number of youth For integration to be International, 2005 Health FP for Youth improving, scaling up visits to the facilities. successful, it is and institutionalizing important to sustain the Ghana Provision of a package of HIV/AIDS prevention. Positive effect on SRH enthusiasm and youth-friendly SRH seeking behaviors, commitment of Peer services including HIV knowledge, attitudes and Service Provides, who counseling and referral for beliefs among peer provide outreach testing and care into educators and youth services and maintain existing RH services in clients. the supply of static clinics and through commodities. outreach.

Silva, 2004 Reproductive Integration of HIV into Aim of the program is After three years of youth Strategies are needed to Health SRH services for youth. to increase in- and out- attendance at clinics increase use of VCT Mozambique of-school 15- to 24- increased by 70% and services among male Peer education and youth- year-olds' awareness of condom use among youth youth. friendly services for SRH issues and to increased by 28%. SRH/FP/STIs and HIV encourage the adoption Provision of VCT may prevention. of safe, responsible, be an entry point to and gender-sensitive HIV services for Youth are counseled on sexual and youths. STI, contraception, reproductive behavior. condom use, and relationships. The literature review revealed that the limited literature on integration of HIV and SRH

services has been focused only on discussions regarding the feasibility, appropriateness,

and social benefits of integrating HIV and SRH services. The studies reviewed

represented all four models of integration discussed in this thesis. A majority of the

studies identified discussed the integration of information and counseling on HIV and

STIs, as well as HIV testing into family planning, antenatal care and post-natal care

settings. Looking at the incorporation of HIV and STI prevention into family planning

services in six clinics in Ibadan, Nigeria, through the provision of counseling on dual protection, Adeokun et al (2002) found that dual protection services increased the uptake

of condoms in the family planning clinics. There was also a resulting increase in discussions of sexual behaviour of clients and their partners.

Other studies looking at the inclusion of HIV services particularly counseling, and testing

showed an increase in access to HIV and SRH services and the uptake of FP services including the use of both female and male condoms (Dehne et al. 2000; Frontiers, 2000;

Adeokun et al, 2002; Horizon, 2002; Fitzgerald, 2003; Babcock, 2004; Best, 2004; FHI,

2004; Abdel-Tawab, 2005; Colton, 2005; Bradley et al. 2008). Also related to the increase in uptake of services was an improvement in quality of services provided (Dehne

& Snow, 1999, FHI network, 2004).

Studies that looked at the integration of FP into HIV settings demonstrate that VCT serves as an appropriate entry point for primary health care services, as VCT generally attracts a population at risk and highly unlikely to visit family planning clinics

(Nierengarten, 2003; Peck et al., 2003; Asiimwe and Hardee, 2005; Gillespie et al.,

48 2007). In addition, these studies also reported an increase in the number of clients accessing both HIV and SRH services as result of integration and an increase in the uptake of family planning services and the use of the contraceptives. Gillespie et al.,

(2007) found that integrating VCT with contraceptive services resulted in higher proportion of males reporting planning to use a contraceptive method in the future after receiving counseling, and both men and women reporting a decrease in desire for more children after finding out their HIV status. Generally, there was an increased demand for

FP services over time. These findings support the desirability of having VCT services integrated into family planning services.

Three studies looking at the integration of HIV information, counseling, and testing into

SRH services for youth reported an improvement in SRH knowledge, attitudes towards sex and increased condom use among youth (Silva, 2004; Pathfinder International, 2005; and Obasi et al, 2006). Silva (2004) found that integration of peer education and youth friendly services for SRH/FP/STIs and HIV prevention in Mozambique resulted in a 70% increase in youth attendance at the clinics and a 28% increase in condom use.

Similarly, a 2005 Pathfinder International study looking at the provision of a package of youth friendly SRH services including HIV counseling and referral for testing and care into existing RH services in static clinics and through outreach, in Ghana found an increase in the number of youth visits to the facilities. The study also found a positive effect on SRH seeking behaviours, knowledge, attitudes and beliefs among peer educators and youth clients resulting from integration of HIV services into existing SRH services for youth. Obasi et al (2006) in their study of integration of information, education and counseling and youth friendly services for SRH/FP and HIV prevention

49 also found a significant increase in condom use and reduction of the number of sexual

partners among the youth.

Studies looking at the integration of HIV prevention, care and treatment services into

SRH settings also found an increase in access and demand for VCT and ART services

resulting in a continuum of care for HIV positive clients (IPPF, 2005).

Overall, although there is a limited evidence base for the integration of HIV and SRH

services in the form of randomized trials and field studies (Myer et al., 2005), majority of

the studies cited reported an increase in coverage and access to both HIV and SRH

services, increased uptake of HIV testing services, use of condoms and other

contraceptives as well as an increase in the quality of services provided. However, one

study identified showed no evidence to indicate that integration of services, particularly integration of FP services in a VCT setting, increases the uptake of VCT services (FHI network, 2004). Apart from increases in service utilization, results from two studies also indicated decreased morbidity rates from STIs and other opportunistic infections resulting from integration of HIV and SRH services (Fitzgerald, 2003; Nierengarten, 2003).

3.8.1 Unanswered Questions

Although the feasibility and benefits of integrating HIV and SRH services have been established, the literature reviewed revealed a lack of systematic analysis of the costs associated with the integration of HIV and SRH services. None of the studies reviewed discussed how integration works or assessed the costs of integration of these services.

Furthermore issues related to economies of scope and transaction costs savings associated with the integration of HIV and SRH services have, by extension, not been examined.

50 3.9 Conclusion

The objective of this chapter was to provide a review of literature on integration of HIV and STI services and reproductive health services. The review presented here defined integration from a health service perspective, provided a history of integration of HIV and SRH services, description of organization of HIV and SRH services, and outlined the feasibility and benefits of integrating HIV and SRH services.

The literature reviewed showed that although many governments have been slow in operationalizing the integration of HIV and SRH services, in countries where efforts have been made to integrate services, the few studies cited reported an increase or improvement in access to and uptake of both FP and HIV services. In particular, integration resulted in enhanced knowledge of HIV and sexually-transmitted infections, an improvement in access to HIV testing, and increased condom use resulting from integration of services. Linking HIV and SRH services has thus been considered beneficial and feasible, especially in family planning clinics and voluntary and counseling centers.

Despite the benefits associated with integrating HIV and SRH services, the literature identifies a number of challenges facing such integration. Key challenges include lack of an adequate legislative framework for ensuring that integrated provision of services is feasible, lack of clear guidelines on implementation, problems in health facilities such as low pay, poor morale, and lack of motivation among service providers, lack of appropriate physical infrastructure and equipment for expanding services, lack of training

51 for staff, and the continual existence of vertical programs which stifle growth of

integrated programs.

Although integration of HIV and SRH services has been found to be beneficial in reducing HIV incidence and improving women's health while meeting the reproductive needs of PLWHA, the understanding of how such integration works and the cost implications of integration are limited. While cost data are limited, still less is understood

about how the integration of HIV and SRH services work. This points to the need for an understanding of the production processes of HIV and SRH service delivery. Such an understanding will provide a basis for the economic analysis of integrated services which may be used to inform policy decisions around integration.

The next chapter therefore embarks on addressing this information gap by developing a tool to describe the production processes of integrated HIV and SRH services in six family planning clinics in Kenya. The chapter also provides a background on Kenya, HIV in Kenya, and Kenya's national response to HIV.

52 CHAPTER 4: BACKGROUND AND METHODOLOGY

Chapter 3 provided a literature review of integrated health services particularly HIV and

STI services and SRH services. The literature reviewed showed an increase or

improvement in access to and uptake of HIV and STI services resulting from integration

of services. However, the literature review highlighted a dearth of economic evaluations

of integrated HIV and SRH services, indicating a gap in knowledge of how integration

works and how resources are combined to produce integrated HIV and SRH services.

The aim of this chapter is to provide specific background information on Kenya and HIV

in Kenya, to discuss the development of the tool used to describe the production

processes in six FHOK clinics in Kenya and the methods used to collect data for the

analysis. The first section will provide a background on Kenya, the HIV situation and the

national response and outline the organization of HIV and SRH services in the Kenyan

context. The next section will restate the aims and objectives of the thesis against this background information. The third section will discuss the methodology of the study and

the development of the tool used for data collection. A brief background on the Family

Health Options Kenya (FHOK) clinics is also provided.

4.1. Kenya

Kenya, a multi-ethnic society in East Africa, is classified as a low income country with a gross domestic product (GDP) per capita of 1,240 Purchasing Power Parity US$ and a ranking of 148 in the Human Development Index (UNDP, 2008). With a population estimated at 33.4 million in 2005 and projected to reach 39.7 million by 2015, Kenya's population has increased rapidly during the past half century, from 8 million in 1960.

53 Kenya has a life expectancy at birth of 52.1 and a total fertility rate estimated at 4.9 live

births per woman in 2007 (KDHS, 2007).

Kenya's economy remains predominantly agricultural based with coffee, tea, and

horticulture as the main agricultural exports. In 2006, Kenya's agricultural sector

contributed about 25 percent of its total GDP, and employed 75 percent of the labour

force (Kenya National Bureau of Statistics, 2006). The agricultural sector's contribution

to Kenya's GDP has declined over the years since the country gained independence in

1964, as the economy has undergone significant structural transformation. Agriculture is

now the second largest contributor to Kenya's GDP, after the tourism-dominated service

sector which contributes about 63% of the GDP.

The performance of the Kenyan economy since 1964 has been mixed. In the decade following independence, the economy grew by 7 per cent per annum. The economic growth was attributed to an increase in agricultural production and an expansion to the manufacturing sector. In the 1980s and 1990s, however, there was a consistent decline in economic growth with the lowest gross GDP growth rate of -0.3 percent in 2000. This poor economic growth was attributed to low commodity prices, poor agricultural policies, internal structural problems, poor infrastructure, and prolonged drought.

Several decades of declining economic performance, coupled with rapid population growth, resulted in increased poverty and unemployment levels and the overall fall in the welfare of average Kenyans. The worsening living standards and subsequent deterioration in health status was reflected in an increase in mortality rates. However, beginning in 2003, Kenya's economy improved as the government launched the

54 Economic Recovery Strategy for Wealth and Employment Creation (ERSWEC) as a road map for economic recovery, aimed at poverty reduction (MOH, 2007). The GDP growth rate rose to 4.0 percent in 2004 and was estimated at 7.0 percent in 2007 (Kenya National

Bureau of Statistics, 2008).

4.2. HIV in Kenya

HIV/AIDS has been described as one of the greatest challenges to Kenya's development.

According to the most recent Kenya AIDS Indicator Survey (KAIS) report of July 2008, more than twenty years since the first HIV case was documented in Kenya, HIV prevalence remains high at 7.4%. The Joint United Nations Programme on HIV/AIDS

(UNAIDS) estimates that about 1.4 million adults (between 15 and 49 years) and an estimated 150,000 children are infected and living with HIV in Kenya (UNAIDS, 2008).

While Kenya's national HIV prevalence is 7.4 %, there are substantial regional variations in HIV prevalence as illustrated in figure 4.1. Nyanza province recorded the highest prevalence at 15.3 percent and other provinces recorded prevalence ranging from 9.0 percent in Nairobi to North Eastern Province which has the lowest adult HIV prevalence at 1 percent (NASCOP, Ministry of Health, 2008). According to the KAIS 2007, the provincial estimates for HIV prevalence among 15 to 49 year olds in 2007 were similar to estimates from the 2003 Kenya demographic health surveys for Nairobi, Central, Eastern and Western provinces.

55 Figure 4.1 Map of Kenya's HIV Prevalence by Province

1

: I.I in t 7

I'It I Ai'l. , , • Western 5.1? I North Eastern 1.0% i ! '

Nyanza 1 '• • ^^

Nairobi 9 0. i

Coast 7.9%

Source: National AIDS and STI Control Programme, Ministry of Health, Kenya. 2008

In terms of sex and age distribution, a higher proportion of women aged between 15 and

64 years (8.7 percent) than men (5.6 percent) are infected with HIV according to the

KAIS 2007. This means that 3 out of 5 HIV-infected Kenyans are female (NASCOP,

MOH, 2008). In addition, the results of the KAIS 2007 indicate that 9.6 %, nearly 1 out of 10, pregnant women in Kenya are infected with HIV.

In Kenya, as in other countries in sub-Saharan African, increased morbidity resulting from HIV/AIDS has negatively affected productivity and eroded the accumulation of human capital and its transfer between generations. In addition to killing millions of people at their most productive age, HIV/AIDS is imposing a significant burden on the

already fragile economy and its overstretched health care system. Although the use of

56 antiretroviral therapy has significantly reduced the number of deaths from ADDS, the increased number of newly infected people means that the impacts of HIV/AIDS will be felt for many decades to come.

Initially, the highest risk of infections was concentrated among marginalized and high- risk vulnerable populations such as commercial sex workers; however, the last two decades have seen rising infections in the general population as well. Kenya therefore has a generalized HIV epidemic, where according to the technical guidelines from the U.S.

Agency for International Development (USAED), the integration of HIV and STI services and reproductive health services are most appropriate. Bearing in mind that women of child-bearing age account for nearly half of the HIV infections, sexual reproductive health services particularly family planning have a critical role to play in curbing the

HIV/AIDS epidemic.

4.3. National Response to HIV/AIDS

In 1999, Kenya declared HIV/AIDS a national disaster and a national coordinating body, the National AIDS Control Council (NACC), was formed. NACC was tasked with the overall responsibility for multi-sectoral resource mobilization, policy, planning, and coordination of the HIV/AIDS response in Kenya. The NACC was to provide leadership in delivering HIV/AIDS prevention, care, and treatment services. It is also responsible for capacity-building and training of health service professionals, developing guidelines for testing and counseling, and accelerating the delivery of anti-retroviral treatment.

NACC facilitated the development of the Kenya National HIV/AIDS Strategic Plan

(KNASP) 2005/06-2009/10, which set out a multi-sectoral response to the HIV/AIDS

57 epidemic, engaging and mobilizing all key social and economic sectors in the national response. The KNASP 2005/06-2009/10 had three priority areas: prevention of new infections in both vulnerable groups and the general population; improvement of the quality of life of people infected and affected by HIV/AIDS; and mitigation of socio­ economic impact of HIV/AIDS.

One of the key intervention strategies identified was the promotion and provision of VCT services to all Kenyans who wish to know their HIV status (FHI, 2006). As a result of the strategic plan, VCT services have increased significantly resulting in a growing number of Kenyans being aware of their HIV status. In addition, a 2000 national guideline for

Prevention of Mother-to-Child HIV/AIDS Transmission (PMTCT), encouraging all pregnant women to know their HIV status has resulted in increased PMTCT services offered across the country.

In October 2007, Kenya's Ministry of Health (MOH) formally approved and adopted the country's first ever National Reproductive Health Policy, with the theme "Enhancing the

Reproductive Health Status for All Kenyans." According to the Ministry of Health

(2007), the policy provided a framework for increasing equitable, efficient, and effective delivery of high-quality reproductive health services throughout the country.

The National Reproductive Health Policy outlined priority actions for improving maternal health, reducing neonatal and child mortality, reducing the spread of HIV/AIDS and achieving women's empowerment and gender equality (MOH, 2007). The policy essentially allowed the government to incorporate and address the integration of HIV and reproductive health, as well as other key emerging issues such as RH commodities

58 security, the prevention of mother-to-child transmission of HIV, emergency obstetric care, adolescent RH issues, gender-based violence, RH needs of persons with disabilities and the elderly (USAID, 2007).

4.4 Organisation of HIV and SRH Services in Kenya

Although the Kenyan government recognizes service integration as an effective means of increasing access to HIV services, FP, HIV and STI control services have largely been implemented through vertical programs administered by separate departments: the

Division of Reproductive Health (DRH) and the National AIDS and STI Control

Programme (NASCOP), in the Ministry of Health. Kenya's DRH is tasked with addressing the components of RH services as decided in the 1994 ICPD and endorsed by

Kenya's reproductive health strategy. These include FP unmet needs, safe motherhood and child survival, management of STDS/HIV/AIDS, promotion of adolescent and youth health care, management of infertility, gender issues and reproductive health rights and other reproductive health issues such as cervical cancer; male involvement in RH, and malaria in pregnancy (Ministry of Health, Division of Reproductive Health).

The NASCOP, mandated by the Ministry of Health, is mainly involved in the technical co-ordination of HIV/AIDS programmes in Kenya. Its programs include counseling and testing, Anti-Retroviral Therapy (ART) programmes, blood safety surveillance, monitoring & evaluation, reproductive health HIV integration, Prevention of Mother to

Child Transmission of HIV (PMCT), home based care (HBC), social & communication programmes, condom advocacy, and treatment of opportunistic infections and STIs.

59 At the service delivery level, the integration of HIV and SRH services varies from facility

to facility. While HIV services increasingly appear to be an integral part of family

planning services, family planning concerns in VCT settings are minimally addressed. In

VCT and PMTCT settings, the focus is on the provision of FP information and a limited

range of non-surgical contraceptives, particularly condoms.

4.5 Thesis Aims and Objectives

Against the background information provided on Kenya and the HIV/AIDS situation in

Kenya, highlighting the need to integrate HIV and sexual reproductive health services,

the aim of this thesis is to examine how resources are combined in the production of HIV

and SRH services in Family Health Options Kenya (FHOK) operated clinics. As a

reminder, this thesis is a part of a broader research project looking at "Assessing the

Benefits and Costs of Integrating HIV services into Sexual Reproductive Health Services

in Kenya, Swaziland and Malawi." Therefore, the focus of this study is to inform the

economic evaluation of various models of integrated HIV and SRH services in Kenya.

To achieve the goal of this thesis, the following objectives, as listed in chapter 1, have

been identified:

i. provide a summary of the relevant economic theory and a review of current literature

regarding integration of HIV services into sexual reproductive health services;

ii. provide a background on the HIV status in Kenya and the national response; iii. develop a tool to describe the production processes of HIV and sexual reproductive

health services in Kenya;

60 iv. describe the production process of integrated HIV/STI and SRH service delivery in six

FHOK clinics; v. discuss the relevance of these findings and their implications for ongoing discussions

on the benefits and costs of integrating HIV and sexual reproductive health services.

4.6 Methodology of Study

The data presented in this thesis was collected as part of the Gates special initiative

project on "Assessing the benefits and costs of Integrating HIV Services into Sexual

Reproductive Health Services." Data was collected by the author through document

reviews, and semi-structured interviews with key clinic staff involved in the provision of

HIV and SRH services, carried out between June and August, 2008. The data collection

was guided by a periodic activity review (PAR) tool developed by the author (See

Appendix A). A list of key informants interviewed is provided as Appendix B.

The next section provides a description of how the PAR was developed.

4.6.1 Development of the Periodic Activity Review Tool

The PAR was developed in May 2008 with an aim to guide the collection of data on how

integration in the FHOK clinics works. The main objectives of the PAR were:

i) To understand the organization and size of the facility.

ii) To review activities and services currently being delivered in each facility.

iii) To understand how integration of services provided in this facility works.

61 iv) To understand the patient flow, by illustrating what happens when a patient comes

into a clinic. v) To understand the nature of existing monitoring. vi) To identify providers of substitute services if any in the community.

The PAR included questions on the description of the facility, the labour mix, the range and scope of services offered, an overall description of how integration of HIV and other services works, target population, how and when integration of services was initiated, staff training on integration, how integration of HIV and SRH services work from the perspective of the service provider, description of client flow, the facility's relationship with other clinics, types of routine monitoring data collected, and indicators for services provided. The data collected was intended to provide a description of the production function of an integrated HIV and SRH service.

The final version of the PAR was completed through a series of steps. The PAR was piloted in the Nairobi West Familycare Medical Centre in June. The piloting of the PAR included three visits to the clinic and interviews with key staff in the clinic. The first interview was held with the centre manager. Following the first interview, the PAR was revised to reduce its length and combine related questions. Subsequent interviews were conducted with the nursing officer in-charge of the facility. Following this interview the author further revised the PAR to streamline the interview process.

Questions on the facility descriptions and client flows were directed to the receptionist rather than the health service providers to reduce the time spent in interviews with the

62 nurse, the doctor or clinical officer. Perceptions of how integration works and the training received by staff were targeted at the individual health service providers involved in provision of HIV and SRH services. The latter section of the PAR was revised to collect data through document reviews. The PAR was slightly revised once more after the piloting process to reflect the difference in staff types in each clinic.

The framework for analysis used for this thesis was developed specifically to collect data related to the delivery of integrated HIV and SRH services. This framework is intended not only to provide insight into how resources are combined to produce integrated HIV and SRH services in the FHOK clinics, hence an understanding of the production function, but also to provide data that can be used for the future economic evaluation of integrated HTV and SRH services in the FHOK clinics.

4.7 Background on Family Health Options Kenya

Family Health Options Kenya (FHOK), formerly known as the Family Planning

Association of Kenya (FPAK), is a non-profit organization and member association of the International Planned Parenthood Federation (IPPF). FHOK operates nine private clinics and five youth centres in Kenya which provide comprehensive health care services including sexual reproductive health services.

The main focus of the Family Planning Association of Kenya (FPAK), formed in 1957, was the provision of family planning services. However, as the emergence of the

HIV/AIDS pandemic shifted global funding priorities from family planning programs to

HIV/AIDS programs, FPAK diversified its services. As a result, the FPAK clinics moved from providing only family planning services to providing more comprehensive family

63 health care services. To reflect this diversity in services provided, the FPAK changed its corporate identity to Family Health Options Kenya (FHOK) in 2006.

As FPAK changed its corporate identity, Family Health Options Kenya (FHOK) progressively began to provide integrated Sexual and Reproductive Health services through eight of its clinics known as FamilyCare Medical Centres. FHOK increased its range of services from vertical family planning to integrated SRH services such as maternal and child health (MCH), maternity, screening for cervical cancer, laboratory investigations, pharmacy, VCT for HIV/AIDS, outpatient treatment and referral.

In 2005, in the wake of an increasing need for access to ART for persons living with

HIV/AIDS, FHOK piloted the Models of Care for Integrating HTV/AIDS Prevention and

Care into Reproductive Health services (MOC) project. The project was aimed at linking the delivery of HIV/AIDS care and treatment to existing family planning and other sexual reproductive health services. The Models of Care project, designed initially for a year, was intended to introduce provision of ART in four of the nine FHOK FamilyCare medical centres: Nairobi West, Thika, Eldoret, and Nakuru clinics. At the inception of the

Models of Care Project, two of the clinics, Nairobi West and Eldoret, were already providing prevention of mother-to-child transmission (PMTCT) services, while seven had

VCT services (IPPF, 2005). By 2008, all the nine FHOK clinics provide VCT and

PMTCT services and eight of the nine clinics provide ART services to PLWHA.

4.8 Conclusion

This chapter has provided background information on Kenya and the HIV situation in

Kenya and also provided a summary of how the provision of HIV and sexual

64 reproductive health services are organized. An outline of the methods used to collect the data for this thesis and a background on the FHOK clinics was also provided.

Kenya's generalized HIV epidemic and prevalence rate of 8.7 % among women of reproductive age has highlighted the importance of integration of HIV and SRH services.

Kenya's National Reproductive Health Strategy (1997-2010) fully acknowledges the relationship between HIV/AIDS and adverse pregnancy outcomes and maternal health.

With regard to HIV and SRH service delivery, while the government officially embraces an integration policy, SRH and HIV services are still largely provided vertically in many government facilities and private clinics, with few exceptions. In government facilities, family planning services are still provided in the maternal and child health (MCH) clinic while HIV counseling, testing and treatment services are provided in the Comprehensive

Care Centers.

Against the background provided on Kenya and the HIV situation, chapter 5 will provide a description of the production processes and nature of integration in one of the models of integrated HIV and SRH service delivery. The results of this study will be analyzed within the theoretical framework presented in chapter 2.

65 CHAPTER 5: PRODUCTION PROCESS OF INTEGRATED HIV AND REPRODUCTIVE HEALTH SERVICES

This chapter aims to describe the production processes of integrated HIV and SRH services and the nature of integration in six FHOK clinics. The production processes will be analyzed in relation to the production function, which as described in chapter 2, represents the total output that can be produced using a combination of inputs and a given technology. While the production function describes the technical relationship between inputs and outputs under the assumptions of cost minimization, the production process describes how the HIV and SRH services are produced.

To achieve this aim, this chapter will provide a description of the six clinics studied, the outputs delivered in each clinic, the input profiles, and a description of the HIV and SRH services production processes in the clinics. The analysis in this chapter will therefore focuses on the combinations of labour inputs and how variations in the number and type of staff affect production processes and the nature of integration in the clinics.

5.1 Description of the Clinics

This section seeks to gain an understanding of the six clinics included in this study. The six clinics are static clinics located in Nairobi West, Nakuru, Eldoret, Kisumu, Meru, and

Thika towns. All clinics provide a similar range of HIV and SRH services which include: the full range of family planning methods and other SRH services including HIV counseling, and testing, PMTCT, treatment of STIs and opportunistic infections, provision of ARVs, adherence counseling and home based care. Table 5.1 provides a description of the outputs produced in the clinics.

66 Table 5.1 Description of Outputs

Output Definition

Family Planning Family planning counseling and provision of family planning (FP) methods, provision of condoms, hormonal contraceptive pills, implants, intra uterine contraceptive devices (IUCD), injectables, vasectomy, and bilateral tubal ligation.

Ante natal care Antenatal care services include health education, general physical (ANC) examination, pre-test counseling, and an antenatal profile which includes the following tests: hemoglobin, HIV test, urinalysis, VDRL for syphilis, malaria parasite, and blood group.

Post-natal care Family planning counseling and method provision, and physical (PNC) examination of the woman post partum.

SRH services for A combination of provision of contraception and treatment of minor youth ailments; VCT and HIV counseling services; post-abortal care; education and entertainment through video, TV and radio programmes; post-rape counseling; general counseling and drug and substance abuse counseling; peer education and counseling training.

Other SRH Includes pap smear for cervical cancer screening, child welfare services services and male circumcision.

Treatment of Provision of syndromic management of STIs, which involves sexually diagnosing and treating STIs based on the patient's symptoms. transmitted infections (STI)

Voluntary Counseling and education on the importance of testing for HTV, counseling and includes the provision of condoms. testing (VCT)

Prevention of Counseling and education on HIV and the benefits of testing, Mother to Child appropriate feeding and delivery options, and provision of ARVs to Transmission of minimize the risk of HIV transmission from mother to child HIV HIV (PMTCT) testing is offered as part of the antenatal profile or sometime before delivery if client has not been attending antenatal care clinics.

67 Table 5.1 (Cont). Description of Outputs

Treatment of Provision of testing and treatment services for opportunistic opportunities infections such as tuberculosis. infections

Antiretroviral Combination of adherence counseling and provision of ARVs to Treatment (ARV) PLWHA.

Home based care Combination of psychosocial support (PSS), nutritional counseling, (HBC) ARV adherence counseling, information and education on prevention strategies for PLWHA.

Community Combination of clinical services, VCT, family planning counseling Outreach Services and provision of contraceptive pills, and referral of clients to the clinics for long time contraceptive methods.

Diagnostic Provision of SRH and HIV testing services such as antenatal profile Services test, pregnancy test, vaginal smears, semen analysis, STI diagnosis, CD4 count tests, and viral load tests.

Pharmacy Services Combination of adherence counseling and provision of contraceptive pills, STI drugs, 01 prophylaxis, and ARVs.

Table 5.2 provides a summary of the clinics, the number of key informant interviews conducted and the types of outputs produced in each clinic. The shaded areas in the table represent the services provided in each clinic. Light shaded areas at the Kisumu clinic illustrate partial coverage of services at the clinic, where services are provided to a particular segment of the population, as will be described in section 5.2.2.

68 Table 5.2 Summary of Clinics included in study

Clinics No of Key SRH Services HIV Services Other Services informant interviews FP ANC PNC SRH Other STI VCT PMTCT ARV HBC Diagnostic Pharmacy for T ' ^ n Nairobi West 8

Nakuru 9 I / Eldoret 10

Kisumu 10

Meru 8

Thika 7

69 5.1.1 Nairobi West Familycare Medical Centre

The Nairobi West clinic located in Nairobi town is the largest of all the FHOK clinics,

serving a catchment population estimated at over 500,000. The clinic provides a full

range of sexual reproductive health services ranging from family planning to provision of

care and treatment for persons living with HIV. Apart from providing outpatient services,

the clinic also has a maternity facility which provides an average of 500 deliveries each

year.

The clinic's laboratory serves as the central laboratory for other FHOK clinics. The

Nairobi West clinic also has a cytology laboratory where all cervical cancer screening

samples from other FHOK clinics are sent for testing.

5.1.2 Nakuru Familycare Medical Centre

The Nakuru Familycare Medical Centre, located in Nakuru town, serves a catchment population of 300,000 people from within Nakuru town and its environs. The Nakuru

clinic provides a full range of family planning and other sexual reproductive health

services, including the provision of care and treatment for HIV positive persons. In

addition to providing HIV services to the general population, the clinic also has a project referred to as the "Pambazuko Project," which is targeted at providing HTV care and treatment to commercial sex workers.

This clinic also has a youth center which provides outreach services, particularly information and education services in the community. The youth centre focuses on peer youth education, provision of counseling services, and training of peer youth educators.

70 5.1.3 Eldoret Familycare Medical Centre

The Eldoret Familycare Medical Centre opened at its present location in 2001 and serves

a catchment population of 300,000. The Eldoret clinic, the second largest of the FHOK

clinics, provides a full range of family planning services and SRH services including maternity services, and HIV care and treatment for persons living with HIV/AIDS. The clinic also has the largest youth centre which provides SRH services, and information and education on SRH issues to over 100 youths aged between 15 and 25 years.

5.1.4 Kisumu Familycare Medical Centre

The Kisumu Familycare Medical Centre is located in Kisumu town, Nyanza province, a region with the highest HTV prevalence (15%) in Kenya (KAIS, 2008). Located in a central location in Kisumu town, the clinic serves a catchment population of 500,000, providing a full range of SRH services and HIV care and treatment. However while SRH services are provided to the general public, STI treatment, and HIV care and treatment services are only provided to commercial sex workers. The clinic also has a youth centre which provides information and education services on SRH issues for youth in Kisumu town.

In addition to the standard clinical services offered in other FHOK clinics, the Kisumu clinic runs two projects: the "Pambazuko Project," a project for commercial sex workers and the Young Men as Equal Partners (YMEP) project. The Pambazuko project introduced at the Kisumu clinic in 2006 provides sexual and reproductive health services including HIV care and treatment, to commercial sex workers in Kisumu town. The

71 YMEP project, on the other hand, is focused on increasing the adoption of safer sexual practices and utilization of SRH services by young men aged between 10 and 24 years.

5.1.5 Meru Familycare Medical Centre

The Meru Familycare Medical Centre located in Meru town, is one of the smaller FHOK clinics serving a catchment population of 200,000. Like the other FHOK clinics, the

Meru clinic provides family planning and other SRH services. Although HIV testing services were provided in the laboratory, the Meru clinic was the last of the six clinics to begin providing VCT services and HIV care and treatment. The clinic first offered VCT and home-based care services in June 2008 while provision of ART did not begin until

November 2008.

5.1.6 Thika Familycare Medical Centre

The Thika Familycare Medical Centre serving a catchment population of about 200,000 is located in downtown Thika, an industrial town 40 km away from Nairobi. Like the

Meru clinic, the clinic is one of the smaller FHOK clinics in terms of staff numbers. The

Thika clinic also provides a full range of family planning services and SRH services including HTV care and treatment. This clinic was one of the four clinics where the

Models of Care Project was piloted in 2005.

5.2 Output Data

A common element in all six clinics is the types of routine monitoring and output data collected. In all six clinics, all clients seeking services are registered at the reception, with the exception of VCT clients. In addition, all service providers maintain a client register

72 in their respective consultation rooms where clients attended to are registered. The daily

activity register records the following information: numbers of clients accessing family

planning services by method; number of referrals by service; number of clients accessing

other SRH services which include HIV testing services through PMTCT, DTC and VCT;

pap smears, STI treatment, ANC, PNC, SRH counseling and maternity services.

All six clinics compile service statistics on a monthly basis which are forwarded to the

FHOK headquarters. Service statistics on HIV, ARV, and maternal and child health are

also forwarded to the Ministry of Health. Output data, referring to the number of each

HIV and SRH services offered in the clinics, was therefore collected from the clinics'

monthly service statistics reports provided to the FHOK headquarters.

5.2.1 Limitations

Since data was collected retrospectively, a number of constraints relating to inaccurate

and missing data were encountered. First, inaccuracies in the data collected in the daily

activity registers at the clinic level made it difficult to determine the exact number of a

particular output produced in the clinics. In addition, in some cases there were

discrepancies between the monthly summary statistics provided to the FHOK headquarters and the data at the clinic level. Secondly, systematic records on HIV

services provided were not always available for all the clinics prior to January 2008.

Inaccurate and missing output data limited the use of data before 2008 for comparisons across clinics.

73 5.2.2 Range and Nature of Outputs

Notable differences in the clinics outputs are determined by the size of the clinic, as well as the natural evolutionary process of integrated service delivery. For example, the Meru and Thika clinics, the smallest clinics, do not provide treatment for opportunistic infections such as tuberculosis due to lack of tuberculosis testing equipment and their proximities to the district hospitals which are better equipped to provide TB testing and treatment. On the other hand, the Meru clinic was the last of the six clinics to integrate

HIV services into its existing SRH services, and therefore was yet to begin providing antiretroviral therapy.

Another difference in outputs produced across the clinics is related to the populations towards which services are targeted. For example, while five of the clinics currently provide HIV care and treatment services to the general public, the Kisumu clinic only provides HIV care and treatment to commercial sex workers. Similarly, while all clinics provide services to the general public including the youth, the Nakuru, Eldoret, and

Kisumu clinics have dedicated youth centers providing information, education and counseling on SRH and HIV issues for the youth.

5.3 Description of Production Processes

Having considered the range of outputs produced in the six clinics, the following section seeks to provide a description of the production processes to achieve these outputs. To gain an understanding of the production processes in the clinics, a total of 52 key informants were interviewed. The key informants included doctors, clinical officers, nursing officers, VCT counselors, laboratory technicians, pharmaceutical technicians,

74 youth centre coordinators and community health workers. Key informants were asked to describe how integration of services works in the clinics and the typical client flow in the clinics.

5.3.1 SRH Services

In all six clinics, clients seeking family planning services, antenatal care , post-natal care, child welfare services and pap smear services for cervical cancer screening were referred to the nurse. A majority of the nurses in all six clinics are able to provide all SRH services with the exception of long term family methods such as tubal ligations and vasectomies which were provided by specialist doctors. However, for curative services, complicated antenatal care, obstetric, and gynecological cases the nurses refer the clients to clinical officer or the doctor.

Youths visiting the three youth centers, Nakuru, Eldoret and Kisumu, are referred to the clinics for curative and family planning services provided by the nurses. Services provided in the youth centers include general counseling, drug and substance abuse counseling, information, education and communication through TV, video and radio programming, and peer youth education on various SRH issues.

5.3.2 HIV Services

Theoretically, all clients seeking SRH services in the clinics should be counseled on

HIV/AIDS, in accordance with WHO Provider Initiated Testing and Counseling (PITC) guidelines. PITC is aimed at ensuring timely detection of HIV, hence prevention of HIV

2 In the Eldoret and Thika clinics, first-time antenatal care clients are referred to the doctor. These clients can be attended to by the nurses during subsequent visits.

75 transmission, and subsequent access to appropriate HIV treatment and support services.

Although all the doctors, clinical officers and nurses in all six clinics are trained in testing for HIV, VCT services in all clinics are provided by the VCT counselor. Therefore, clients who present symptoms of HIV-related illnesses during consultation visits for other services or those who wish to be tested for HIV are referred to the VCT counselor. In five of the clinics: Nairobi West, Nakuru, Eldoret, Kisumu and Meru, the laboratory technologist may also provide VCT, particularly to clients who make self-requests for

HIV tests.

On the other hand, PMTCT services, offered in the Nairobi West and Eldoret clinics, are provided in the maternity by nurses. In both cases, clients who test positive for HIV are referred to the doctor for further observation. VCT clients who request family planning services are referred to the nurses, since a majority of the VCT counselors are unable to provide family planning services beyond basic family planning counseling.

With regards to other HIV testing, the laboratory facilitates CD4 count and viral load tests by collecting samples which are referred to various facilities with which the clinic maintains relations. Table 5.3 provides a summary of the CD4 count test referral sites for each of the clinics.

Table 5.3 CD4 Referral Sites

Clinic Lab Referral Site

Nairobi West clinic Kenya Medical Research Institute (KEMRI), Nairobi

Nakuru clinic Kenya Medical Research Institute (KEMRI), Nairobi

Eldoret clinic Academic Model Providing Access to Healthcare, Eldoret

76 Table 5.3 (Cont.) CD4 Referral Sites

Clinic Lab Referral Site

Kisumu clinic Family AIDS Care and Education Services (FACES), Kisumu

Meru clinic Meru District Hospital, Meru

Thika Clinic St. Murumba Mission Hospital, Thika

Clients who are started on antiretroviral therapy following their viral load and CD4 count test results are introduced to the community health workers who provide ARV adherence, nutritional counseling and counseling on positive living. In addition to providing counseling services to the PLWHA, the community health workers also form post-test support groups in the communities to provide psychosocial support to PLWHA. Clients seeking curative services, STI treatment and treatment for other opportunistic infections are referred to the doctors or the clinical officers for treatment. In the Nakuru and Eldoret clinics, the nurses are also able to provide syndromic management of STIs, although generally such clients will usually be referred to the clinical officer or the doctor.

Generally, there were not very significant differences between the production processes in the clinics. In all six clinics, the role of the doctors and the clinical officers is limited to providing curative services for general ailments, treating opportunistic infections and

STIs, assessing the clients CD4 count and prescribing ARVs for HIV-positive clients.

Although some of the doctors and clinical officers have training in provider-initiated counseling and testing (PITC), VCT, PMTCT, and family planning, in all six clinics, clients seeking HIV counseling and testing are usually referred to the VCT counselor while clients seeking family planning services, and maternal and child health services are

77 referred to the nurses. Post-natal care clients who require FP counseling and method provision, well baby clinic clients and well woman (which includes cervical cancer screening, breast exam) clients are also referred to the nurses.

Differences in the production processes were mainly in the provision of HIV testing and adherence counseling for rational use of ARVs. In all six clinics, diagnostic testing services, which include HIV tests, are provided by the laboratory technician. However, in the Thika clinic, the laboratory does not provide HIV testing unless a client has been counseled and referred to the laboratory by the VCT counselor.

While in all six clinics, prescription drugs including ARVs are dispensed by the pharmaceutical technologists, adherence counseling on use of ARVs is not provided by the pharmaceutical technologist in all clinics. In two clinics, the Kisumu and Thika clinics, ARV adherence counseling is provided by the pharmacy. In the other four clinics,

Nairobi West, Nakuru, Eldoret, and Thika, adherence counseling is provided by the community health workers.

5.4 Output Data Analysis

A summary of the total number of HIV and SRH services provided in the six clinics between January and June 2008 is provided in table 5.4. The percentages were calculated based on the total outputs produced in each clinic. Generally, as indicated by the figures in table 5.4, SRH services (mostly family planning) form the larger percentage of total output produced in the clinics, accounting for 59% of total outputs produced. Overall,

HIV services make up approximately 40% of the total outputs produced in the clinics.

78 Examining the individual clinics, the Meru clinic reported the highest percentage of SRH

services produced with 94.06% of all outputs being either family planning or other SRH

services. The Kisumu clinic on the other hand, produced the lowest percentage of SRH

services with only 33.13% of all outputs being SRH services. The higher percentage of

HlV-related services in the Kisumu clinic relative to SRH services can be explained by

the high HIV prevalence rate in the region. The Meru clinic produced fewer HIV related

outputs (5.94% of total output) because full integration of HIV services into the existing

SRH services did not occur until June 2008.

Looking at the disaggregated outputs, the Kisumu and Nakuru clinics reported the highest percentages of STI treatment services provided at 25.92% and 16.02 % respectively. This high percentage of STI treatment services relative to other outputs can be attributed to the clinics' focus on providing STI treatment services to commercial sex workers. In relation to VCT/PMTCT/DTC, the Eldoret and Kisumu clinics reported the highest percentages of VCT/PMTCT services with 34.74% and 34.34% respectively of all outputs produced in the clinics being VCT/PMTCT and diagnostic testing and counseling services. This reflects the relatively higher HIV prevalence rates in the two areas and hence the need for more HIV testing services.

With regard to home-based care services, although at the clinic levels, service providers reported having provided home based care services, only the Nakuru and Eldoret clinics reported data for home-based care during the period spanning from January to June 2008 in their monthly summaries provided to the FHOK headquarters. These were reported at

2.08% and 13.85% respectively of all outputs produced in the clinics.

79 Table 5.4 Summary of Clinics Outputs for Jan - June 2008

Sites SRH Services HIV Services

FP Other SRH STI/OI Treatment VCT/PMTCT/DTC ARVS HBC

N= % N= % N= % N= % N= % N= %

Nairobi West 1632 30.09% 1984 36.58% 292 5.38% 828 15.27% 574 10.58% 113 2.08%

Eldoret 2956 29.41% 2142 21.31% 46 0.45% 3491 34.74% 23 0.23% 1392 13.85%

Nakuru 2041 39.82% 1024 19.98% 821 16.02% 772 15.06% 467 9.11% 0 0%

Kisumu 1609 28.22% 280 4.91% 1478 25.92% 1958 34.34% 377 6.61% 0 0%

Meru 4786 81.73% 722 12.66% 232 3.96% 116 1.98% 0 0% 0 0%

Thika 1906 40.00% 734 15.41% 621 13.04% 1121 23.53% 382 8.02% 0 0%

Total Outputs 14930 6886 3490 8286 1823 1505

% of Total Outputs 40.44% 18.65% 9.45% 22.44% 4.94% 4.08% Produced 5.5 Input Profiles

SRH and HIV services like other services are produced from a combination of inputs.

The main input in this discussion is labour. Table 5.5 provides a description of key staff involved in the provision of SRH and HIV services in the clinics.

Table 5.5 Key Staff involved in Provision of SRH and HIV Services

Staff Type Description of Key Roles

Doctor Provides all clinical services including treatment for STIs, opportunistic infections, and prescription of anti-retroviral therapy.

Clinical Officers In clinics where there are no doctors, the clinical officers provide clinical services for all ailments, including HIV care and treatment of opportunistic infections and prescription of ARVs.

Nurses Provide maternal and child welfare services including family planning, immunization, growth monitoring, pap smears for cervical cancer screening, breast examination, antenatal care, PMTCT and post-natal care services.

VCT Counselors Provide pre- and post-HIV test counseling at the static clinics and during mobile community outreaches held by the clinics. Apart from providing HIV counseling and testing, the VCT counselors are able to provide basic family planning counseling and provide condoms but refer the clients to the nurses for surgical contraceptives methods.

Community Health CHWs provide home-based community care services for PLWHA; follow up of Models of Care clients for ARVs and TB drugs adherence; Workers (CHWs) provide FP information and counseling, including dual protection, to HIV + clients accessing ART, PMTCT, STI, and VCT services; facilitate referrals for clients to access ANC, PMTCT, STI treatment, and VCT services at the clinic; conduct awareness-creation activities with community members to promote their access to and use of FP- integrated HIV services; and facilitate weekly support group meetings for PLWHAs to provide psychosocial support, treatment adherence counseling and nutritional counseling.

Laboratory Technician The laboratory technologists or technicians provide routine laboratory tests including reproductive health testing such as pregnancy, and HIV testing. The laboratory technicians facilitate the collection of samples for CD4 count, viral load testing at other facilities.

81 Table 5.5 Cont. Staff involved in Provision of SRH and HIV Services

Staff Type Description of Key Roles

Pharmaceutical The pharmaceutical technologist or technicians dispense drugs for all Technologist ailments and infections; provide contraceptive pills, vaccines, and female and male condoms. The pharmaceutical technologists also provide adherence counseling for HIV positive clients on the use of anti-retro viral treatment (ART).

5.4.1 Labour Mix

Labour input varies from clinic to clinic. The number of staff is generally determined by the location and the catchment population of the clinics. The type of staff is also determined by the location of the clinic and the range of services provided. Table 5.6 provides a summary of the labour mix in the six clinics.

The relative percentage difference in the staff types reflects the size of the clinics, the catchment population, and the scope of services provided in the clinics. The Nairobi West and the Eldoret clinics are the largest of the six clinics while the Meru and Thika clinics are the smallest in terms of staff types and total output produced. For example, with the exception of the Kisumu & Thika clinic, nurses form a larger percentage of the paid staff in the other four clinics: 51.62% in Nairobi West, 5.88% in Nakuru, 17.30% in Eldoret, and 20% in Meru. In the Nairobi West and Eldoret clinics, this is because the two clinics provide maternity services and therefore require more nurses than other types of staff. In the Nakuru clinic, in addition to the services offered to the general public at the Nakuru clinic, the clinic also provides family planning and HIV services for commercial sex workers which requires the services of an extra nurse.

82 The Kisumu clinic has a large percentage of clinical officers at 14.29% not only because of its large catchment population, but also because of the number of projects targeted at different populations in the clinic. One of the clinical officers is solely dedicated to the

"Pambazuko Project", which provides SRH and HIV services to commercial sex workers, while the other two provide clinical services to the general population.

The large proportion of VCT counselors in the Eldoret and Kisumu clinics (5.77%; and

23.81% respectively), relative to other staff in the clinics, reflects the higher HIV prevalence rates in these two communities, and as such an increased demand for HIV counseling and testing services.

Although each of the three clinics with youth centers have one youth centre coordinator each, representing 1.96%, 1.92% and 4.76% of the total staff respectively, the Nakuru and Eldoret clinics have a higher percentage of peer youth educators which reflects the focus on youth friendly services in these two clinics.

Despite the variations in numbers and type of staff from one clinic to another, one commonality among the clinics is the roles of similar staff types. For example in all clinics the nurses provide all family planning and maternal and child health services, while the clinical officers or the doctors provide curative services including HlV-related treatment and the VCT counselors provide HIV counseling and testing.

83 Table 5.6 Summary of Clinics Labour Inputs

Staff Type Clinics

N. West Nakuru Eldoret Kisumu Meru Thika

n= % n= % n= % n= % n= % n= %

Doctors/Specialist Doctors3* 7 22.6 - - 6 11.54 - 1 10.00 1 12.50

Clinical Officers - - 2 3.92 1 1.92 3 14.29 1 10.00 - -

Nurses 16 51.62 3 5.88 9 17.30 2 9.52 2 20.00 1 12.50

VCT Counselors 1 3.22 1 1.96 3 5.77 5 23.81 2 20.00 2 25.00

Community Health Workers 2 6.45 2 3.92 2 3.85 2 9.52 2 20.00 2 25.00

Youth Centre Coordinator - - 1 1.96 1 1.92 1 4.76 - 0 -

Pharmacists/Pharmaceutical Techs 3 9.68 1 1.96 1 1.92 1 4.76 1 10.00 1 12.50

Laboratory Technologists/Techs 2 6.45 1 1.96 2 3.85 2 9.52 1 10.00 1 12.50

Community Outreach Workers4 - - 5 9.80 - - 5 23.81 - - - -

Youth Peer Educators - - 35 68.62 27 51.92 ------

N= 31 51 52 21 10 8

The Nairobi West and Eldoret Family Care Medical Centers, which have maternity wards, also have specialist doctors such as gynecologists, obstetricians, pediatricians and anesthetists. However, the specialists are not full time Family Health Options Kenya. 4 The Community outreach workers and youth peer educators are volunteers at the clinics. Although the input composition is similar in the six clinics, there are variations in total outputs produced in the clinics. The variations in total outputs produced can be explained more by the location of the clinics and availability of substitute services around the clinics than by the number and types of staff in the clinics. The Nairobi West, Nakuru and

Kisumu clinics are in urban areas where there are a number of substitute services available to clients, whereas the Meru clinic is located where there are relatively fewer substitute services available hence its higher output per capita.

Nevertheless, in some cases the variation in total outputs produced in the clinics can be explained by further examining the type of staff in clinics of a similar size. For example, the large number of outputs in the Eldoret clinic relative to the Nakuru clinic can be attributed to the higher percentage of doctors and nurses providing SRH-and HIV-related services in the Eldoret clinic. Similarly, examining the disaggregated outputs, we note that although the Kisumu clinic has the highest number of VCT counselors, the clinic provided fewer HIV counseling and testing services compared to the Eldoret clinic. This difference could be explained in part by the higher percentage of nurses in the Eldoret clinic providing maternity services, hence PMTCT services relative to the Kisumu clinic which has far fewer nurses and does not provide PMTCT services.

5.6 Discussion

Having described the outputs produced and the production process in relation to the input profiles of the six clinics, the following sections will present an analysis of the production processes in relation to the models and forms of integration as presented in chapter 3.

85 5.6.1 Models of Integration

As already mentioned, all six clinics included in this study were originally exclusively family planning clinics. Family planning services therefore form the pre-existing infrastructure into which HIV and STI counseling, testing, treatment, and care are provided. These clinics represent two main models of integration: HIY/STI integrated into family planning, ANC and PNC services; and integration of HIV/STI services into

SRH services for youth in the case of the Nakuru, Eldoret and Kisumu clinics.

As discussed in chapter 3, integrating HIV services with SRH in these clinics has been beneficial in increasing the knowledge of HIV prevention strategies among women of reproductive age who are at high HIV risk but might not otherwise receive HIV counseling and information. In addition, youths receive information, education and counseling on SRH and HIV related issues and referrals for curative services, including

STI treatment, family planning services, and HIV testing, through the youth centers without being stigmatized.

An element of the third model of integration, integration of family planning into HIV care and treatment, is also visible in all six clinics as community health workers are increasingly involved in the provision of limited family planning services to PLWHA during home-based care visits. In all six clinics, the community health workers are able to provide basic family planning counseling but refer clients to the clinics for provision of family planning methods and other HIV-related services.

86 5.6.2 Forms of Integration

The production processes in the six clinics illustrate the two main forms of integration: vertical and horizontal integration. As discussed in chapter 3, vertical integration, defined as the coordination of service lines that are at different stages of production, refers to the provision of a broad range of patient care and support services in one facility. Horizontal integration, on the other hand, involves interrelationships between or among two or more health facilities providing similar services.

In all the six clinics, the coordination of different levels of services and the provision of a broad range of patient care services in one facility, demonstrates vertical integration. On the other hand, the interrelationships between the clinics and other health facilities, as illustrated by referrals for a few services such as CD4 count testing services in all six clinics and TB treatment in the Meru and Thika clinics, supports a claim for some level of horizontal integration in the clinics. Through cooperation with other health providers offering similar services, the clinics are able to provide a wider scope of services to their clients.

In relation to service delivery, the predominant type of integration in all six FHOK clinics is structural integration. As defined in chapter 3, structural integration refers to the creation of one complex organization consisting of many different parts, able to perform various tasks. Structural integration is illustrated in all six clinics by the provision of comprehensive HIV and SRH services in the same facility through specialized units such as maternal and child health clinics, VCT centre and youth centre. In this case, in all six clinics, the roles of the staff are clearly defined where family planning, maternal and

87 child health services are provided by the nurses; curative services, STI treatment and treatment of HIV related infections and ARV prescriptions are provided by the doctor or the clinical officer; HIV counseling and testing services are provided by the VCT counselor; and home-based care, adherence and nutrition counseling are provided by the community health workers.

However, it is worth noting that although in all six clinics, services are still provided by different providers in different rooms within the same location, service providers are becoming increasingly able to provide both SRH and HIV related services in the same room as integration of services continues to evolve.

5.7 Conclusion

The main aim of this chapter was to present the results of the data collection and analysis of the production processes and nature of integration in six FHOK clinics. Information on outputs and inputs were collected through key informant interviews, document reviews and observations of service delivery. The semi-structured interviews were guided by the periodic activity review guide described in chapter 4. The final results described the production processes in the six clinics, providing valuable insight on how integration of

HIV and SRH services work.

First, all six clinics, formerly family planning clinics, currently provide a similar range of

SRH and HIV services. The results of the analysis of the outputs produced in each clinic in relation to input profiles, suggests that the variation in the level of integration of HIV and sexual reproductive health services in each of the clinics can be explained by the

88 location of the clinic relative to the HIV prevalence rate and the availability of substitute

services as well as by the number and type of staff in the clinic.

The input composition with respect to the staff types was also similar across the clinics.

Examining the input allocations across the clinics, it is clear that the type and number of

staff plays a significant role in determining the level and nature of integration in the clinics.

Generally, there were not very significant differences in the production processes between the six clinics. Notable distinctions between the production processes in the six clinics surround the differences between the roles of the staff which is, in part, reflected by the training the service provider has received. It could be concluded that the more trained staff, particularly nurses, that a clinic has, the greater the ability of the service provider to provide integrated services.

The discussion of the production processes in the clinics reveals vertical integration as the predominant type of integration where a wide range of outputs are produced within the same facility. In addition, there is an element of horizontal integration where provision of a few services is ensured through referral systems. With regard to service delivery, services are structurally integrated as each service provider, provides different services in the same location.

The next chapter provides a summary of this thesis and conclusions useful for the future economic analysis of such integrated HIV and SRH service delivery as well as the policy implications of the analysis presented in this thesis.

89 CHAPTER 6: CONCLUSION

This chapter concludes the thesis with a summary of the chapters presented in the thesis

and how the objectives set out in chapter 1 have been met. The thesis set out to fill the

gap in the knowledge existing of the production processes of integrated HIV and SRH

services. The thesis began with a summary of relevant economic theory, followed by a

review of current literature regarding integration of HIV into SRH services. A

background on the HIV situation in Kenya, the national response and methodology of the

study was provided. The results of the data collection and a detailed analysis of the

production processes in six FHOK clinics was also provided.

6.1 Background in Economic Theory

Chapter 2 presented the economic theory underpinning integration of health care services.

The economic theory discussed can be applied to the integration of HIV and SRH

services since the theoretical framework relating to the production and delivery of HIV

and sexual reproductive health services is similar to the production of any other service.

Of significance to this discussion is how firms, in this case health service providers, make

decisions to maximize output given a set of inputs and technology.

Key economic concepts related to integration of service provision and delivery, namely economies of scope and transaction cost theory, were also presented. Joint provision of services using the same inputs is expected to result in lower production and service delivery costs. Transaction costs economics provides a rationale for integration of service provision as producers and firms resort to integration of services in a bid to lower the transaction costs associated with the delivery of services separately.

90 6.2 Literature Review

Chapter 3 presented a review of the literature on integration of HIV and STI services and sexual reproductive health services. The literature reviewed showed that in countries where efforts have been made to integrate HIV and SRH services, the few studies cited reported an increase or improvement in access to and uptake of both FP and HIV services. Integration also resulted in enhanced knowledge of HIV and sexually transmitted infections and increased condom use resulting from integration of services.

Linking HIV and SRH services has thus been considered beneficial and feasible especially in family planning clinics and voluntary and counseling centers.

However, the literature review revealed a dearth of economic analysis of integrated HIV and SRH service delivery. This was attributed in part to a lack of knowledge of how integration of services works. As a first step in filing the knowledge gap this thesis set out to develop a tool for analyzing the production processes of integrated HIV and SRH services in six FHOK clinics.

6.3 Background and Methodology

Chapter 4 provided background information on Kenya and the HIV situation. It also provided a summary of the organization of HIV and sexual reproductive health services at the policy level as well as at the delivery level. Kenya's generalized HIV epidemic and prevalence rate of 8.7 % among women of reproductive age highlighted the importance of integration of HIV and SRH services in Kenya. With regard to HIV and SRH service delivery, while the government officially embraces an integration policy, the integration of SRH and HIV services still faces a number of challenges. As such, SRH and HIV

91 services are still largely provided vertically in many government facilities and private

clinics, with few exceptions.

This chapter also presented the methodology of the study and discussed the development

of the periodic activity review tool used to collect data for the study. Input and output

data was collected through key informant interviews, documents review and observation

of health service providers using the periodic activity review as a guide. A background on

the FHOK clinics was also provided.

6.4 Production Processes of HIV and SRH Services

Chapter 5 described the production processes in six FHOK clinics in relation to the production function. In terms of inputs, only labour input was considered in this

discussion. The final analysis described the production processes in the six clinics, i.e. how provision of integrated HIV and SRH services work.

The analysis of the production processes reveals that the delivery of HIV and SRH

services is similar in the six clinics. The key difference between the production processes was the difference in roles played by staff in service provision. In five of the clinics, HIV counseling and testing services are provided by the VCT counselor or laboratory technician. Curative services are provided by the doctor or the clinical officers and FP,

ANC and PNC services are provided by the nurses. The pharmaceutical technician dispenses ARVs and contraceptives and provides adherence counseling for HIV positive clients on ARVs in two of the clinics. In the other four clinics, adherence counseling for

ARVs is provided by the community health workers.

92 6.5 Conclusion

Overall, the objective of this thesis was to contribute to the knowledge of how integration works by developing a tool to describe the production processes of integrated HIV and

SRH services in six FHOK clinics. The results of this analysis revealed a slight variation in the level of integration and nature of integration in the delivery of HIV and SRH services from one clinic to another. A key consideration in this discussion is thus the substitutability of service providers in the context of integrated service delivery.

New knowledge gained from this study includes an understanding of the production processes of integrated HIV and SRH services in high HIV prevalence settings. An understanding of the production processes of HIV and SRH services is important for deriving human resource requirements for such integrated HIV and SRH service delivery.

The results of this analysis therefore provide valuable insights and information useful for future expansion of services in the FHOK clinics as well as the economic analysis of integrated HIV and SRH service delivery in these clinics.

There are a number of limitations to this analysis that should be noted. First, as service delivery in all health care settings evolves with the addition of new services and changes in staffing levels, it is possible that the data collected during this study may have changed since the analysis was done.

Second, most of the data was collected through face to face, key informant interviews, which are subject to bias making it difficult to prove validity of findings. Furthermore, missing output data, inaccuracies in the recording of output data and discrepancies between service statistics collected at the clinic levels and the FHOK headquarter level,

93 could not guarantee the accuracy of statistics used for this analysis. This may present

challenges in drawing conclusions with regard to output per capita and efficiency of

service delivery.

Another limitation to this analysis was the use of only the number of labour inputs in the

analysis. The analysis of the production processes would have benefited from the use of

staff time allocation data and the time needed for provision of different types of services

as a basis of comparison.

Although it has been assumed that integration of HIV and SRH services is cost-effective,

there is currently a scarce evidence-base on the costs and cost-effectiveness of

integrated interventions to support this hypothesis. In light of this, an area of further

research is a full economic evaluation of integrated HIV and SRH service delivery in the

FHOK clinics. As such the results of the present analysis will provide a basis for the

development of a costing protocol for the future economic evaluation of integrated HIV

and SRH services. A full economic costing of integrated HIV and SRH services will provide insight into the cost consequences of integration in the HIV/SRH context and provide evidence that may be used to inform policy decisions around the delivery of HIV

and SRH services.

There are several conclusions resulting from this analysis that may have policy implications. First, as noted in chapter 3's discussion of the challenges to integration, staff training and increased competence among health service providers to be able to provide both SRH and HIV services is critical. The extent to which service providers can offer integrated services depends not only upon resources available but also on staff

94 training. Integration therefore remains more of a myth than a reality if a service provider is unable to provide a range of services due to lack of adequate training in the provision of a service.

Second, national stock-outs of commodities such as contraceptives and HIV test kits, negatively affect integration of services. Therefore to achieve effective integration of

SRH and HIV services, to ensure that the SRH needs of PLWHA are met, the Kenyan government must make serious efforts in ensuring a supply of reproductive health commodities to meet the public's demands for SRH and HIV services. Policies to ensure these demands are met are, therefore, of utmost urgency.

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101 APPENDIX A: PERIODIC ACTIVITY REVIEW TOOL

Economic Analysis of Integrated SRH and HIV Services in Kenya

Periodic Activity Review of Facilities providing Integrated SRH & HIV Services Topic Guide for Information Collection

Revised July 31, 2008

100. Facility Name:

101. Contact Person:

102. Date of Activity Review:

102 Introduction This periodic activity review is intended to document the nature, range and method of delivery of sexual reproductive health and HIV services in each project facility. Specifically, we would like to understand how service integration is working in this facility.

The periodic activity review has the following objectives: 1. To understand the organization and size of the facility. 2. To review activities and services currently being delivered in each facility. • To understand the evolution of services i.e. was a service previously provided? How long has the service been delivered for? • To identify new services or activities planned and the likely timeframe. • To understand what other facilities/services patients are referred to? 3. To understand how integration of services provided in this facility works. 4. To understand the patient flow, by illustrating what happens when a patient comes into a clinic. 5. To understand the nature of existing monitoring. • What indicators are collected and how are they collected? E.g. For age, are the actual ages noted down or is a patient labeled as either youth or adult? • What information is actually entered and who enters the information? Is it the patient or the service providers? What is collected in paper or electronic form? 6. To identify providers of substitute services if any in the community. 7. To feed into the development of a costing protocol.

This instrument is designed for members of the economics team to collect information through interviews with key staff and observation of activities in each project facility. Organization of the Topic Guide Section 1: Interviews with the receptionist and observation focusing on facility description, services offered and patient/client flows. Section 2: Interviews with the clinic manager focusing on the process of integration of services. Section 3: Interviews with other health service providers in the facility e.g. nurses, VCT counselors focusing on service integration from their point of view and client/patient flow. Section 4: Records review at the FHOK headquarters level and clinic levels.

103 Topic Guide for Periodic Activity Review Section 1: Interviews with Receptionist la. Description of Facility

lb. Facility Operating Hours

Mon Tues Wed Thur Fri Sat Sun

lc. Facility size (number of rooms available). A separate sheet is included to draw a map of the rooms in the facility

1. Waiting rooms 5. Theatre 9. VCT Rooms

2. Consultation rooms 6. Maternity Wing 10. Youth Centre

3. Laboratory 7. Pharmacy 11. Community Health Workers Room

4. Other 8. Other 12. Other

Id. What are the types of staff currently working in the facility?

Doctors (D) Pediatricians (PE) Medical Centre Attendant

Clinical Officer (CO) Radiologists (R) Community Health Workers (CHW)

Senior Nursing Officers Pharmaceutical Drivers (D) (SNO) Technologist (P)

Nurses (N) Lab Technicians Cleaners (CLR) (LTs)

Midwives (M) VCT Counselors Day Guard (C)

Gynecologists/Obstetricians Accounts Assistant (OBGYN)

Anesthetists (A) Receptionist/Acc'ts Clerk (AC) le. How many staff does the clinic have?

Full Time/On Contract Interns

Part Time/Locum: Volunteers

104 Topic Guide for Periodic Activity Review Section 1: Interviews with Receptionist

If. Map of the Facilities - This is a sketch of the physical layout of the facilities. Numbers refer to category of room from question A2 above. Confirm sketch with the receptionist.

105 Topic Guide for Periodic Activity Review Section 1: Interviews with Receptionist

SERVICES OFFERED lg. Overall Description of SRH And HIV Related Services Offered Does your facility offer the following integrated sexual and reproductive health products and services? For services offered, please also indicate what type of staff provides the service (i.e. doctor, nurse, lab tech). Yes Staff type involved in No Where are clients service provision referred to? Contraceptive pills, injectables, and implants Vasectomy and bilateral tubal ligation Male and female condoms Post partum FP ANC and PNC Voluntary counseling and testing AR Provision and Adherence Counseling CD4 Count PMTCT STI treatment and prophylaxis Male circumcision and minor surgery Maternity/Gynecological services Child health services Pap smear for cervical cancer screening Post rape care Post abortion care and manual vacuum aspiration Management of Opportunistic Infections including TB Unwanted/ Teenage Pregnancy Counseling Management of infertility Education on adolescent sexuality General FP counseling Youth friendly services Curative services Lab services Pharmacy

106 Topic Guide for Periodic Activity Review Section 1: Interviews with the Receptionist lh. Are there any other services or activities other than those indicated above, offered in the facility? Please list and include date service began. Service Start date Staff type involved in service provision

li. Service provision hours. Are all the services listed in lg and lh provided daily? If not, when are they provided?

107 Topic Guide for Periodic Activity Review Section 1: Interviews with the Receptionist

CLIENT FLOW

Client Flow - Observation/Interviews with the receptionist lj. Please describe a typical client visit. I.e. Who does the client see upon arrival at the clinic and then what happens. E.g. Someone comes in for FP who is not pregnant and doesn't want to get pregnant. Attach room numbers etc. How many doors do they need to go through?

Ik, A pictorial representation of patient flow

Based on the map of the clinic, show the different sequential locations that the patient visits.

108 Topic Guide for Periodic Activity Review Section 2: Interviews with the Clinic Manager

2a. Brief description of how the facility is organized or draw organigram. If available get a copy of an organization chart if any. Include a personal introduction of interviewee. ' 1. Personal introduction of interviewee-how long he/she has worked in the clinic

2. Organization of the clinic 3. Type of clinic (mobile/static clinics) 4. Range of services provided in the clinic 5. Target population. 6. Relationship with other clinics around

109 Topic Guide for Periodic Activity Review Section 2: Interviews with the Clinic Manager

INTEGRATION OF SERVICES

2b. When did service integration in this facility begin? Last Year 2 Years ago 3 Years ago More than 3 Years ago 2c. How was service integration initiated?

2d. Was there any training on service integration provided to Yes No staff? If Yes, provide a summary of the training provided and names/titles of the clinic staff who attended.

2e. How does integration of services work? Focus on integration of HIV services into FP/VCT and VCT/STI into FP Describe the type of integration currently in the facility. I.e. is it structural or functional. Structural integration is defined as provision of different services by different people under the same roof while functional integration is defined as provision of different services by the same person in the same room/facility.

110 Topic Guide for Periodic Activity Review Section 2: Interviews with the Clinic Manager

2f. Has provision of any of the integrated services provided in the Yes No clinic been disrupted?

If yes, which service and why? Service Inconsistent Staff Other (Please describe Supplies / Shortages e.g. Political crisis) Stock Outs

2g. Are there any new services/activities (both SRH and non-SRH) that are yet to be implemented? If yes, please provide details including the likely timeframe. Service Expected implementation date. Are they included in the annual plan?

2h. Substitute Services - Who else provides similar types of products and services within the community?

Service Service Provider Location

2i. Why do clients return to this FHOK Clinic despite the presence of other substitute service providers

2j. Are there any fees charged for services provided in the clinic? If fees are charged, how are fees for services determined?

111 Topic Guide for Periodic Activity Review Section 3: Interviews With Other Service Providers

3a. Brief introduction of service provider

3b. Have the service provider received any training on service Yes No integration? If yes, provide a summary of training received and when training was received.

3c. How does integration of HIV into SRH services work? From the service providers' point of view.

3d. Client Flow Description of a typical client visit from the Service Providers Point of View

112 Topic Guide for Periodic Activity Review Section 3: Interviews With Other Service Providers

3a. Brief introduction of service provider

3b. Has the service provider received any training on service Yes No integration? If yes, provide a summary of training received and when training was received.

3c. How does integration of HIV into SRH services work? From the service providers point of view.

3d. Client Flow Description of a typical client visit from the Service Providers Point of View

113 Topic Guide for Periodic Activity Review Section 3: Interviews with Other Service Providers

3a. Brief introduction of service provider

3b. Has the service provider received any training on service Yes No integration? If yes, provide a summary of training received and when training was received.

3c. How does integration of HIV into SRH services work? From the service providers point of view.

3d. Client Flow Description of a typical client visit from the Service Providers Point of View

114 Topic Guide for Periodic Activity Review Section 3: Interviews with Other Service Providers

3a. Brief introduction of service provider

3b. Has the service provider received any training on service Yes No integration? If yes, provide a summary of training received and when training was received.

3c. How does integration of HIV into SRH services work? From the service providers point of view.

3d. Client Flow Description of a typical client visit from the Service Providers Point of View

115 Topic Guide for Periodic Activity Review Section 3: Interviews with Other Service Providers

3a. Brief introduction of service provider

3b. Has the service provider received any training on service Yes No integration? If yes, provide a summary of training received and when training was received.

3c. How does integration of HIV into SRH services work? From the service providers point of view.

3d. Client Flow Description of a typical client visit from the Service Providers Point of View

116 Topic Guide for Periodic Activity Review Section 4: Clinic Records Review

4a. When was clinic established?

4b. When did provision of integrated services begin?

Monitoring and Evaluation 4c. In what form are client records kept? Electronic Paper 4d. What cards, registers are used to collect client information? Do the registers have titles or are they by service? Type of card/register with # of registers Information Information Where client information at clinic or cards collected by collected for card/regist level (e.g. FHOK er is kept /IPPF or MOH)

-

4d. What types of routine monitoring data is collected in these registers?

117 Topic Guide for Periodic Activity Review Section 4: Clinic Records Review

4e. What are the titles/audience and frequency of the different summary reports prepared for this clinic? (include code or id to be used in 4f) Report title Report prepared for Frequency of report* Who prepares report?

118 Topic Guide for Periodic Activity Review Section 4: Clinic Records Review

4f. Indicators for services provided. Please provide process indicators for monitoring integrated services provided in the facility (Table to be filled out looking at existing records and registers) Service Indicators Where are these How long have indicators indicators been reported? collected for (indicate start year):

119 Topic Guide for Periodic Activity Review Section 4: Clinic Records Review

Service Indicators Where are these How long have indicators indicators been reported? collected for (indicate start year):

120 Topic Guide for Periodic Activity Review Section 5: General Observations

Notes - General Observations

121 Topic Guide for Periodic Activity Review Section 5: Contact Information

List of People (Positions and Contact details) talked to.

Contact Name Position Contact Details

122 APPENDIX B: LIST OF KEY INFORMANTS INTERVIEWED

Nairobi West Family Care Medical Centre

Dr. David Murigi Doctor/Centre Manager [email protected].

Sister Rose Ngahu Senior Nursing Officer

Nicodemus Kimeu Senior Nursing Officer

Edwin Nyanja VCT Counselor

Ken Ongubo Senior Lab Technologist

Doris Nkatha Receptionist

Dr. Louis Machogu Pharmacist lmachogu @fhok.org

Hellen Masama CHW [email protected]

Eldoret FamilyCare Medical Centre

Francis Owiti Clinical Officer/Centre Manager [email protected]

Sister Martha Achesi Senior Nursing Officer

Joseph Otieno Youth Centre Coordinator [email protected]

Jacinta Kiragu CHW

Isaiah Khang'ati CHW

John Telia Nurse- Midwife

Joy Kerubo Lab Technologist

Sister Phoebe Ruto Nursing Officer

Selinah Cherutich Pharmacy Technologist S [email protected]

George Karanja VCT Counselor

Nakuru FamilyCare Medical Centre

Methuselah Ocharo Clinical Officer/Centre Manager [email protected]

Sister Beatrice Runo Senior Nursing Officer

Mary Muthamia Receptionist

123 Nakuru FamilyCare Medical Centre Cont.

Sister Jemima Ntwiga Relief Nurse

Sam Sambrumo Clinical Officer, Pambazuko Project

Joe Muranga Pambazuko Project Coordinator

Moses Muriuki CFIW/VCT Counselor [email protected]

Sister Perpetua Wetangula Nurse, Pambazuko Project [email protected]

Jane Anyango Adero CHW [email protected]

Kisumu FamilyCare Medical Centre

Geoffrey Luttah Clinical Officer/Centre Manager geofrey luttah @ y ahoo .co .uk

Thomas Otengo Clinical Officer [email protected]

Dinah Odoyo Nursing Officer

Ezra Kiprotich Clinical Officer

Phoebe Wekesa Wafula Nursing Officer

Caroline Kambona YMEP Project Coordinator

Friedah Origa Pambazuko Project Coordinator [email protected]

George Ngolo Youth Centre Coordinator

Benjamin Odhiambo Medical Centre Attendant

Andrew Appoppa Accounts Clerk/Receptionist

Meru FamilyCare Medical Centre

Timothy Ngure Wachira Clinic Manager [email protected]

Peterson Mwangi Receptionist/Accountant [email protected]

David Nakitare Lab Technologist

Faith Kanini Pharmaceutical Technologist

Steven Mwangi Nursing Officer [email protected]

Damaris Muriungi VCT Counselor

124 Phyllis Kagwiria VCT Counselor

Fredah Mbwiria Community Health Workers

Thika FamilyCare Medical Centre

Dr. Daniel Kamau Clinic Manager Dr .kamau 122 @ gmail.com

Sister Patricia Mwiko Nurse

Salome Nyoike Community Health Worker

Okanda Moses Community Health Worker

Benjamin Muchiri Pharmaceutical Technologist

Francis Odhiambo VCT Counselor

Mary Ndungu VCT Counselor

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