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

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

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

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

Study design Non-randomized sampling of 10 health facilities (3 OSS and 7 IR ) : each with an ART and a FP clinic 12 months data coverage: October 2013 - September 2014 Unit of analysis with respect to efficiency is the ART clinic Population of interest: female ART patient of reproductive age

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

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

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

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

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

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

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

Thank you www.hfgproject.org