1. Integration of Family Planning: Case Study in Manyara Region National Family Planning MCH/HIV Stakeholders Meeting Giraffe Hotel, Dar Es Salaam September 24 - 25 Ikupa Akim, Consultant, EngenderHealth/Tanzania

2. Outline Background Methodology Key Findings (CHMTs/ Providers) Achievements (CHMTs/ Providers) Challenges (CHMTs/ Providers) Lessons Learned (CHMTs/ Providers) Conclusions

3. Background EngenderHealth supported scale-up of PMTCT with integrated FP at RCH sites in Manyara; now supports 146 sites out of 151; Established integration of HIV care and treatment into RCH in 18 facilities in Manyara region in 2012; Now 144 sites option B+; Broader integration of FP into multiple entry points initiated in 2013.

4. Methodology Integration defined as provision of FP methods or HIV services by providers at point of entry (other than usual entry point); The case study was conducted in three districts in Manyara region – Babati Town Council, Babati and Hanang District Councils; A total of 4 facilities visited: Babati/Mrara Hospital – Babati TC Gallapo Health Centre – Babati DC Magugu Health Centre – Babati DC Tumaini District Hospital – Hanang DC

5. Methodology Data collection: Key informant interviews with CHMT members and providers Review of facility service statistics Document review 35 Key informant interviews: 9 CHMT members 26 providers

6. KEY FINDINGS Integration in Manyara: A case study

7. Service Availability and Integration FP methods provided vary according to the type of facility, infrastructure available, unit within facility, and provider training; Integration sites: RCH, OPD, Maternity/post-natal, Female and Paediatric wards, CTC; Post-delivery, clients are counselled on FP methods and can be given condoms, PPIUD or minilaps; most are given condoms; Short-term methods have been the easiest to integrate in units other than RCH; Not all providers are able to provide FP methods; Facilities collect service statistics at the various entry points; Integration has worked better in hospitals and health centres, has had more challenges at dispensary level.

8. Figure 1: Proportion of Clients Accessing FP Services Outside of RCH

9. Increased uptake of both FP and HIV services; Increased access of services by clients who fear being stigmatised; Increased client satisfaction; Achievements Identified by CHMTs Decreased opportunity cost for clients; Providers work more efficiently, e.g. saved the time of escorting referral clients; RCH has been decongested; Provider knowledge and satisfaction has increased.

10. Achievements Identified by Providers Increase in users of FP methods; Reduction in unintended pregnancies; More potential clients have been reached with messages and counselling; Less attrition of CTC clients; Increases in service utilisation due to decreased waiting times; Reduction of stigma regarding use of FP methods; More cPAC clients are leaving facilities with FP method; Facilities capture more women of high parity who come to facility but not to RCH; Increased number of women initiating ART through RCH.

11. Challenges Identified by CHMTs Lack of skilled staff; Lack of infrastructure and space to ensure privacy; Inconsistent supply of commodities; Attitude/culture of some clinicians who do not see FP service provision as part of their mandate; Integrating FP services in the OPD; High workload interferes with FP service delivery at points of entry; Tracking of individual clients is a challenge; Inadequate resources for supervision.

12. Challenges Identified by Providers Additional workload affects quality of service; High volume of forms to be filled for each client; Infrastructure is inadequate to ensure privacy for clients; Not enough trained providers to ensure integrated services in all units; Shortage of equipment, tools and commodities; Creating demand that cannot be met; Tracking of clients who initiate methods outside of the RCH.

13. Lessons Learned: CHMTs Integration has helped to reduce barriers to accessing FP; Improves skills, because the provider offers multiple services; Reduces missed opportunities for accessing services (FP and HIV); Makes reaching women of high parity who come to facility but not to FP clinic easier; Maximizes limited human resources; however the human resource shortage needs urgent attention; Promotes holistic management of patients.

14. Lessons Learned: Providers Integration has reduced stigma; Reduced pregnancy rates in HIV positive women; Improved quality of service; Integration has allowed providers to serve more clients; Post-delivery FP, when women are more accepting of FP services, is a golden opportunity for increasing users; Through integrated services more people have been reached with FP methods.

15. Conclusions CHMTS and facilities are been able to implement Integrated services in Manyara and achieve success Implementation of integrated of services is customized to reality of individual facilities CHMTs and facilities have embraced integration as an opportunity to improve efficiency and quality of services

16. Discussion Points What can be done to improve clinician ownership of FP services? What can be done to streamline monitoring and reporting process? Can FP services be integrated into all non-IPD units? How can facilities strengthen delivery of FP services post- delivery?

17. Asanteni!