Abstract
BackgroundThe body of knowledge on evaluating complex interventions for integrated healthcare lacks both common definitions of ‘integrated service delivery’ and standard measures of impact. Using multiple data sources in combination with statistical modelling the aim of this study is to develop a measure of HIV-reproductive health (HIV-RH) service integration that can be used to assess the degree of service integration, and the degree to which integration may have health benefits to clients, or reduce service costs.Methods and FindingsData were drawn from the Integra Initiative’s client flow (8,263 clients in Swaziland and 25,539 in Kenya) and costing tools implemented between 2008–2012 in 40 clinics providing RH services in Kenya and Swaziland. We used latent variable measurement models to derive dimensions of HIV-RH integration using these data, which quantified the extent and type of integration between HIV and RH services in Kenya and Swaziland. The modelling produced two clear and uncorrelated dimensions of integration at facility level leading to the development of two sub-indexes: a Structural Integration Index (integrated physical and human resource infrastructure) and a Functional Integration Index (integrated delivery of services to clients). The findings highlight the importance of multi-dimensional assessments of integration, suggesting that structural integration is not sufficient to achieve the integrated delivery of care to clients—i.e. “functional integration”.ConclusionsThese Indexes are an important methodological contribution for evaluating complex multi-service interventions. They help address the need to broaden traditional evaluations of integrated HIV-RH care through the incorporation of a functional integration measure, to avoid misleading conclusions on its ‘impact’ on health outcomes. This is particularly important for decision-makers seeking to promote integration in resource constrained environments.
Highlights
Using multiple data sources in combination with statistical modelling the aim of this study is to develop a measure of HIV-reproductive health (HIV-RH) service integration that can be used to assess the degree of service integration, and the degree to which integration may have health benefits to clients, or reduce service costs
Since the 1990s there has been an assumption that integration of HIV-related services (e.g. HIV testing, condom provision, and HIV treatment) with family planning (FP), antenatal care (ANC) and postnatal care (PNC) services, would streamline service delivery
This paper aims to contribute to the field of complex intervention evaluation, as well as the broader policy debate on health service integration, by describing the development of a tool to measure the degree of HIV-RH integration achieved in the health facilities studied: the Integra Index
Summary
Since the 1990s there has been an assumption that integration of HIV-related services (e.g. HIV testing, condom provision, and HIV treatment) with family planning (FP), antenatal care (ANC) and postnatal care (PNC) services, would streamline service delivery. It is difficult to assess the extent to which services are integrated, and whether the delivery of integrated services leads to cost savings, greater client satisfaction, and/or improved patient outcomes. Using multiple data sources in combination with statistical modelling the aim of this study is to develop a measure of HIV-reproductive health (HIV-RH) service integration that can be used to assess the degree of service integration, and the degree to which integration may have health benefits to clients, or reduce service costs
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