Examining the links between staff flexibility, workload, and service delivery in the context of SRH and HIV service integrationS. Sweeney, C.D. Obure, F. Terris-Prestholt, C. Michaels, C. Watts, the Integra Research Team, A. Vassall

Background: Integration of HIV and SRH services

may yield improvements in efficiency Economies of scope Economies of scale

Despite a clear rationale for integration, there is scarce evidence on the costs and potential efficiency gains of integrated service provision

Methods (1) Baseline: 2008-09 Endline: 2010-11 Kenya: 24 public facilities, 6 private facilities Swaziland: 8 public facilities, 2 private

facilities

Core MCH services: family planning (FP), post-natal care (PNC), antenatal care (ANC)

Non-core services: STI management (STI), voluntary HIV testing and counselling (VCT), provider-initiated HIV testing and counselling (PITC), cervical cancer screening (CaCx), and HIV treatment and care

Methods (2): Data Sources Key informant interviews with staff, time

sheets and direct observations of services Staff time was allocated as a percentage of

clinical staff full-time equivalency (FTE) according to service mix and time use

Workload was estimated as the number of outpatient visits per clinical staff FTE per day

Process and output data collected from routine monitoring registers Service was considered ‘present’ if > 10 visits

recorded per year, and if staff FTE was > 0

Methods (3): Data Analysis Objectives:

Observe the improvements in resource integration from baseline to endline

Identify the relationship between non-core service availability and human resource integration

Evaluate the effect of improvements in integration on staff workload

Data analysed in Stata and Excel Due to small sample sizes and potential

confounding factors, this analysis is descriptive

Resource Integration Indicators Human Resource Integration Physical Resource Integration Service Availability in the MCH Unit Service Availability in the Facility

Example: HIV Testing and Counselling<--- More integrated Less integrated --->

HCT conducted for all MCH clients within MCH unit, by MCH nurses

MCH clients referred to a separate HCT unit, staffed by HCT counsellor or lab technician

HCT referred out to a separate facility

RESULTS

Baseline(2008-2009)

Endline(2010-2011)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Human Resource Integration Physical Resource Integration Service availability in MCH/FP unit Service availability in facility

Perc

enta

ge o

f Tot

al P

ossib

le R

ange

of

Serv

ices

Changes in Resource Use Indicators from Baseline to Endline

Changes in Resource Use Indicators from Baseline to Endline (2)

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39-300%

-200%

-100%

0%

100%

200%

300%

400%

500%

600%

700%Changes in Resource Integration Indicators

% Change in Physical Resource Integration

% Change in Human Resource Integration

% Change in service availabil-ity in the MCH/FP Unit % Change in service availabil-ity within the fa-cility

Facility Number

Perc

ent

Chan

ge f

rom

Bas

elin

e

Improvements in Resource Integration from Baseline to Endline

8 19 5 35 12 26 13 15 18 31 30 1 29 36 39 4 7 21 24 37

Physical Resource Integration Improved

Human Re-source In-tegration Improved

Service Availability Within the Facility Im-provedService Availability within MCH Unit Im-proved

Facility Number

INCREASE IN SCOPE

Increase in Scope: Which services are added / dropped?

PITC Ca Cervix Screening

STI PITC (stand alone)

HIV Care and

Treatment

VCT

MCH Unit Facility Level

-15

-10

-5

0

5

10

n = 4n = 7

n = 4n = 1

n = 3

n = 4

n = 12

n = 6

Changes in Service Mix from Baseline to Endline

Facilities Adding Service Facilities Dropping Service

Num

ber

of F

acili

ties

Increase in Scope:Patterns in Human Resource Integration

PITC Ca Cervix Screening

STI HIV Care and Treatment

VCT -40%

-30%

-20%

-10%

0%

10%

20%

30%

40%32% 33%

13%

-28%

-6% -6%

16%

1%

-3%

7% 4% 1%

Service Mix and HR Consolidation in MCH unit

Service Added Service Dropped No Change

Perc

ent c

hang

e fro

m b

asel

ine

in

num

ber o

f ser

vice

s pr

ovid

ed p

er

staff

CHANGES IN WORKLOAD

Variation in staff workload

0 20 40 60 80Workload (Outpatient Visits / Staff FTE / Day)

VCT Visit

STI Visit

PNC Visit

PITC Visit

HIV Care and Treatment Visit

FP Visit

Ca Cervix Screening Visit

Staff Workload at Baseline and Endline

Baseline Endline

HR Integration and staff workload

CaCx (p = 0.44)

FP(p = 0.26)

STI(p = 0.28)

PITC(p = 0.06)

VCT(p = 0.42)

HIV Care(p = 0.78)

0

5

10

15

20

2522

1817

15

7 7

18

22 21 22

9 9

Less Integrated (n = 58)

Staff

Wor

kloa

d (V

isits

/Sta

ff/Da

y)

Changes in Staff Workload and HR Integration

Ca Cervix Screening

Visit(p = 0.53)

PITC Visit(p < 0.00)

STI Visit(p = 0.12)

VCT Visit(p = 0.89)

HIV Care and Treatment

Visit(p = 0.19)

-8-6-4-202468

1012

3

-5-3

-1 -1

5

10

5

-1

-7

Changes in Workload and Human Resource Integration

Least change in HR integration (n = 29)Most change in HR integration (n = 11)

Chan

ge in

visi

ts p

er st

aff F

TE p

er d

ay fr

om b

asel

ine

to e

ndlin

e

Implications for policy Integration was not scaled up uniformly; readiness

assessment should precede integration policy PITC, cervical cancer screening and STI services

can potentially be more easily incorporated into MCH unit

Integration may be a way to improve workload in underworked facilities

However, policy makers should also be careful about overworking staff in the context of supplier-induced demand

AcknowledgementsMinistry of Health, SwazilandMinistries of Health, Kenya

Family Health Options Kenya (FHOK)Family Life Association of Swaziland (FLAS)

Learn more at:www.integrainitiative.org

Support for this study was provided by the Bill & Melinda Gates Foundation. The views expressed herein are those of

the author(s) and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation

For a copy of this presentation please visit same.lshtm.ac.uk

Changes in integration indicators over time: very little change on aggregate levelService Availability in

MCH/FP Unit (out of 5)

Service Availability in Facility

(out of 8)

Human Resources Integration

(out of 5)

Physical Resources Integration(out of 5)

2008-2009

2010-2011

Difference

2008-2009

2010-2011

Difference

2008-2009

2010-2011

Difference

2008-2009

2010-2011

Difference

CountryKenya (n = 30) 2.23 2.30 0.07 6.10 6.56 0.43 1.88 1.92 0.04 1.29 1.29 0.00Swaziland (n = 10) 2.20 2.30 0.10 6.70 7.00 0.30 1.36 1.00 -0.36 1.15 1.18 -0.03

Facility TypeHospital (n = 2) 3.00 3.00 0.00 8.00 8.00 0.00 2.77 1.79 -0.99 0.98 0.59 -0.39District Hospital (n= 5) 2.20 2.40 0.20 7.80 7.80 0.00 1.94 2.33 0.39 1.37 0.89 -0.48Sub District Hospital (n = 6) 2.00 1.83 -0.17 6.33 6.33 0.00 2.00 1.75 -0.26 1.16 1.03 -0.13Health Centre (n = 17) 1.41 1.52 0.12 5.35 6.18 0.82* 1.15 1.21 0.08 0.71 0.96 0.25*Public Health Unit (n = 2) 2.50 3.00 0.50 5.50 6.50 1.00 0.77 0.35 -0.56* 0.88 0.80 -0.08SRH Clinic (n = 8) 3.87 3.87 0.00 6.87 6.87 0.00 2.72 2.54 -0.17 2.57 2.61 0.03

ModelFP (n = 12) 2.42 2.50 0.08 6.58 6.86 0.25 2.31 2.41 0.09 1.27 1.23 0.04PNC (n = 20) 1.45 1.55 0.10 5.80 6.49 0.65 1.03 0.92 -0.11 0.72 0.75 0.03SRH (n = 8) 3.87 3.87 0.00 6.87 6.87 0.00 2.72 2.54 -0.17 2.57 2.61 0.03

LocationRural (n = 23) 1.56 1.61 0.04 5.61 6.24 0.61* 1.37 1.35 -0.01 0.83 0.97 0.15Urban (n = 17) 3.12 3.23 0.12 7.12 7.24 0.12 2.26 2.13 -0.13 1.83 1.65 -0.18

Ownership TypePrivate (n = 8) 3.87 3.87 0.00 6.87 6.87 0.00 2.72 2.54 -0.17 2.75 2.61 -0.03Public (n = 32) 1.81 1.92 0.09 6.09 6.63 0.50 1.51 1.47 -0.35 0.92 0.92 0.00

Increase in Scope: Impact on Utilization

-1000

-500

0

500

1000

1500

2000

2500

3000Service Mix and Utilization at Facility Level

Service Added

Service Dropped

No Change

Ave

rage

cha

nge

in a

nnua

l out

pati

ent

visi

ts f

rom

bas

elin

e to

end

line

Variation in Facility Outputs

0 2,000 4,000 6,000

Total Annual Outpatient Visits

VCT Visit

STI Visit

PNC Visit

PITC Visit

HIV Care and Treatment Visit

FP Visit

Ca Cervix Screening Visit

four outliers over 20000 excluded

Total Outpatient Visits at Baseline and Endline

Baseline Endline

Average Change in Staff Workload 2008-2009 2010-2011

p value (t-test)

F ratio (p value) (ANOVA)

Country   0.86 (0.36) Kenya (n = 30) 17.42 15.17 0.32 Swaziland (n = 10) 13.81 15.36 0.68 HR Integration   2.04 (0.16) Least change (n = 29) 17.72 14.88 0.19 Most change (n = 11) 13.34 16.09 0.50 Facility Type 4.71 (0.00) Hospital (n = 2) 10.71 24.87 0.52 District Hospital (n= 5) 15.86 15.65 0.95 Sub District Hospital (n = 6) 10.11 16.24 0.13 Health Centre (n = 17) 19.40 10.54 0.00 Public Health Unit (n = 2) 17.60 21.78 0.68 SRH Clinic (n = 8) 16.79 20.04 0.46  Model 0.87 (0.43) FP (n = 12) 16.25 14.67 0.67 PNC (n = 20) 16.57 13.61 0.27 SRH (n = 8) 16.79 20.04 0.46 Location 6.51 (0.01) Rural (n = 23) 16.97 12.03 0.04 Urban (n = 17) 15.90 19.52 0.21  

Variation in staff workload0

2000

040

000

6000

080

000

Tota

l MC

H v

isits

0 20 40 60 80Average Facility Workload

Baseline Endline

Facility Workload and Outpatient Visits