Integration of HIV and Nutrition Services –

Action and MeasurementBarbara Engelsmann, Sweden Chiruka, Charity Zvandaziva, Fitsum Assefa,

Diana Patel

Abstract No MOAE0102Session Title: Integrated HIV, Health and Human Development Programs

20th International AIDS Conference Melbourne, Australia20-25 July 2014

What is Integration?

Integration means different things to different people:

Integration of type of services Integration referring to service delivery

points Integration of services over time Integration of vertical levels of service Integration at policy/management level

WHO definition: “The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.”

Why Integration?

Resource constraints – available resources have to be used as efficiently as possible Rise of single disease funding or population group specific programs Different disease goals based on common service delivery resources Client oriented, closer to the goal of universal access For smaller programs integration might be survival

Why NOT Integration?

Risk of reduced quality of service provision Challenges to showcase achievements AIDS exceptionalism –

“it is important to regard HIV/AIDS services as a special case which needs to be well-resourced, expanded quickly and protected from the inefficiencies of the broader health system”

Integration of HIV (PMTCT/ped. HIV) and Nutrition (IYCF/CMAM) services

IYCFCMAM

PMTCTPediatric

HIV

• Mutual dependence of HIV and nutrition services Yet Largely vertical implementation of their programs to date

• Potential to maximise on different entry points for service provision

• PILOT PROGRAM to integrate service delivery for HIV and nutrition

• WHERE: Three country program (in Zimbabwe, Malawi and Mozambique)

• SUPPORT: Funded by DFATD through UNICEF

• WHEN: Over three years (July 2011 to June 2014)

In Zimbabwe:

• 32 sites in two rural districts(Marondera and Hwedza)

Implementation: by the Organization for Public Health Interventions and Development (OPHID) trust in Zimbabwe linked to/leveraged by existing PMTCT program

Integration - Activities

At national/provincial levelStimulation of policy dialogue at national level

Sensitization at provincial level

At service delivery levelSkills building

Encouragement of bi-directional linkages and referral systems

Supervision and mentoringDevelopment of job-aides

At community levelMobilization of

Voluntary community cadresTraditional leaders

Mother-baby support groups

At outreach levelCapacity building of outreach teams

Training and sensitization of village health workers

Integration - Monitoring & Evaluation

To monitor the delivery of service integration specific integration indicators were defined measuring the concurrent provision of HIV and nutrition services at different service delivery points

Examples: % of children with SAM receiving HIV

testing % of children in pediatric ART program

screened for SAM

Indicator 1: % PMTCT clients with children under 2 years of age receiving at least 2 IYCF counselling sessions

Indicator 2: % HIV exposed infants attending DPT3 immunization who are exclusively breastfed

Indicator 3: % children in pediatric ART program screened for SAM

Jan-Jun 2012

Jul-Dec 2012

Jan-Jun 2013

Jul-Dec 2013

0

10

20

30

40

50

60

70

80

90

100

Indicator 1Indicator 2Indicator 3

Indicator 4: % children with SAM receiving HIV-testingIndicator 5: % of HIV positive children at CMAM enrolling on ART

Jan-Jun 2012 Jul-Dec 2012 Jan-Jun 2013 Jul-Dec 20130

10

20

30

40

50

60

70

80

Indicator 4Indicator 5

Integration – Success

Baseline integrated service delivery

Program interventions to promote service integrations

Recording of indicators to define and prompt integrated service delivery

Integration now measurable

Outcome: Integrated service provision increased

Integration – Challenges

Action Challenges:

In particular at higher level

Monitoring and Evaluation Challenges: Information required for integration indicators originating

from different source registers (CMAM register, ART register, EPI register) at different service delivery points over a period of time

Enumerators and denominators were not always routinely available as part of the national M&E system eg IYCF counseling provided, currently breastfeeding

Integration – Recommendations

Support of integration efforts at national level (even if different departments are involved)

More attention to national routine M&E tools to include measures for integration and set targets for integration indicators

Next Steps: Impact analysis Cost-effectiveness analysis

Acknowledgements

President’s Emergency Plan for AIDS Relief through USAID under the terms of Families and Communities for Elimination of Pediatric HIV in Zimbabwe (AID-613-A-12-00003)

Disclaimer“This study was made possible by the generous support of UNICEF and the American people through the U.S President’s Emergency Plan on AIDS relief (PEPFAR) and United States Agency for International Development (USAID). The contents are the responsibility of OPHID and do not necessarily reflect the views of UNICEF, DFATD, PEPFAR, USAID or the United States Government”

UNICEF HQ, regional and country office

And many more….

Zimbabwe Ministry of Health and Child Care

Department of Foreign Affairs, Trade and Development Canada