Integration of Family Planning and HIV Services in Malawi: An Assessment at the Facility Level

Publication date: 2015

This publication was prepared by Laili Irani, Erin McGinn, Madison Mellish, Olive Mtema, and Pierre Dindi of the Health Policy Project. INTEGRATION OF FAMILY PLANNING AND HIV SERVICES IN MALAWI An Assessment at the Facility Level December 2015 HEALTH POL ICY P R O J E C T Suggested citation: Irani, L., E. McGinn, M. Mellish, O. Mtema, and P. Dindi. 2015. Integration of Fam ily Planning and HIV Services in Malawi: An Assessment at the Facility Level. Washington, DC: Futures Group, Health Policy Project. ISBN: 978-1-59560-136-0 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activ ities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). Integration of Family Planning and HIV Services in Malawi An Assessment at the Facility Level DECEMBER 2015 This publication was prepared by Laili Irani,1 Erin McGiin,2 Madison Mellish,2 Olive Mtema,2 and Pierre Dindi2 of the Health Policy Project. 1 Population Reference Bureau, 2 Futures Group The information prov ided in this document is not official U.S. Government information and does not necessarily represent the v iews or positions of the U.S. Agency for International Development. iii CONTENTS Acknowledgments . iv Executive Summary. v Abbreviations . vii Introduction . 1 Study Objectives .3 Methods . 4 Data Collection .6 Integration Models . 8 Results. 8 1. Facility Audits.8 2. Interviews with Facility In-charges . 10 3. Interviews with Providers. 11 4. Clients . 12 5. Mystery Clients . 14 6. Focus Group Discussions . 17 Discussion . 21 Extent of FP-HIV Integration . 21 Demand for Integrated Services . 22 Availability of Contraceptives and Method Choice . 22 Current State of Referrals . 23 Provider-initiated Family Planning (PIFP) . 23 Respectful Care. 24 Public vs. CHAM vs. UNFPA-supported Sites . 24 Other Issues for Further Investigation . 25 Recommendations . 25 Conclusion. 27 References. 28 Annex A. Data Analysis . 31 Annex B. Calculations for Client Exit Interviews . 53 Annex C. Questionnaires Administered at Facilities . 54 Appendix C1: Facility Audit, in English . 54 Appendix C2: Questionnaire Guide, in English, Administered to Facility In-charge. 64 Appendix C3: Questionnaire Guide, in English, Administered to Health Service Provider. 75 Appendix C4: Client Flow Analysis, in English. 88 Appendix C5: Questionnaire Guide, in English, Administered to Clients . 90 iv ACKNOWLEDGMENTS The authors would like to thank Nyanyiwe Mbeye and Fannie Kachale for assisting with the study design and institutional review board application. We appreciate the contributions of Betty Farrell, particularly her review of the data collection tools. We also thank all the data collectors and mystery clients involved in the study, particularly our data quality assurance consultants, Julius Chingwalu, Esther Kip, and Albert Dube. We also appreciate the participation of the district health officers and all the respondents who gave their time to participate in the study. We would like to acknowledge the valuable technical review we received from our colleagues Sara Bowsky, Jay Gribble, and Ron MacInnis. v EXECUTIVE SUMMARY Malawi has issued several policies and strategies that speak to integrating family planning (FP) and HIV services. In particular, Malawi has HIV service delivery guidelines—Clinical Management of HIV in Children and Adults—that recognize the need to prevent unwanted pregnancies regardless of HIV status. These guidelines emphasize the need for dual protection and introduce the practice of provider-initiated family planning (PIFP) as part of HIV counseling and testing (HCT) and the clinical management of HIV clients over the age of 15. At the request of the USAID Mission in Malawi, the USAID-funded Health Policy Project (HPP) undertook a comprehensive facility-based assessment to ascertain the extent to which FP services have been integrated into HIV services in Malawi through different integration models and across various types of facilities (public and non-profit private). The study was also designed to examine how the reproductive rights of people living with HIV (PLHIV) are being respected and addressed through approaches such as PIFP and access to method choice. Finally, the study aimed to identify any systems-level barriers to integration and provide practical recommendations for the Ministry of Health (MOH) and other stakeholders to improve FP-HIV integrated services in Malawi. Data was collected through facility audits (n=41), interviews with providers (n=122) and in-charges (n=41), client exit interviews (n=425), mystery client visits (n=58), and focus group discussions (n=3). The study was implemented across nine districts in the North, Central, and Southern regions. Of the 41 facilities, 19 were public health centres/posts, nine were public hospitals, seven were hospitals or health centres operated by the Christian Health Association of Malawi (CHAM), and six were public integrated health centres supported by the United Nations Population Fund (UNFPA). This study found that significant efforts are being made to integrate FP into HIV services across Malawi. The type of integration and the extent to which integration efforts have been successful have depended on health systems characteristics, such as facility type, provider training, availability of antiretrovirals (ARVs) and FP methods, and the state of referrals. While notable advances have been achieved in integrating FP and HIV services, the health system is not yet successfully integrating FP into antiretroviral therapy (ART) services as envisioned in national policies and ART clinical guidelines. Key findings include: • ART clients have a high need for effective FP services. Over half (52%) of female clients reported not wanting another child. Only a few clients were currently pregnant (n=17), and most of these women reported the pregnancy as mistimed (n=9) or unwanted (n=4). The majority of female clients (60%) were using contraception, but half relied on condoms and another one third were using injectables. Only a handful were using the most effective reversible methods—implants or intrauterine devices (IUDs). • National guidelines on PIFP are largely not being implemented. Only 22 percent of clients reported ever being asked about FP at the ART clinic, and only 14 percent had been asked that day. Only two of the mystery client visits (out of 58) documented PIFP. Lack of provider training may be a contributing factor. Only one-quarter of providers reported receiving training related to FP-HIV integration, and one-fifth had received no FP training at all. • ART clients do not have easy access to a range of FP methods. Overwhelmingly, HCT and ART clinics rely on condoms to meet clients’ FP needs. Only 10 percent of HCT clinics and 31 percent of ART clinics had injectables available for clients. Only 20 percent of ART clinics had a full range of FP methods (short- and long-acting, hormonal and non-hormonal) available to clients. • Referral systems are inadequate and hinder clients from accessing FP. Providers reported routinely referring ART clients for FP, either internally, to another facility, or for Banja la Mtsogolo (BLM) outreach services at the same facility but at a later date. However, many providers lacked vi details on referral services, such as the days and times those services were available and the transport costs to reach the referral site. • Commodity stockouts continue to hinder service delivery, particularly in the public sector. Almost half of the facilities (44%) reported problems with FP stockouts. None of the UNFPA- supported facilities reported FP stockouts. About one-third reported stockouts of HCT kits. ARV stockouts were also reported by one-quarter of facilities, all of which were public sector facilities. • While many facilities had updated FP, HCT, or ART client registers to accommodate integrated services, several did not. Moreover, a few facilities were operating without registers on the day of data collection. This suggests current monitoring and evaluation systems and data are not capturing the full picture of how integrated services are being operationalized. • Client responses suggest a demand for integrated services. Almost all ART clients (97%) expressed a preference for receiving their services in a fully integrated manner (same clinic/room, same day), and 90 percent said they would be willing to wait longer to get multiple services per visit. The opportunity costs entailed in seeking health services may be a major issue for clients. Over three- quarters of clients cited fewer trips to the facility as a benefit of receiving integrated FP-HIV; 43 percent cited reduced travel costs as a benefit. This stands to reason, as the same proportion of clients reported traveling more than one hour to reach the facility. • Clients may not know where integrated services are available. Only 22 percent of HCT clinics and 37 percent of ART clinics had FP-related information, education, and communication (IEC) materials displayed. Only 42 percent of FP clinics had HIV-related IEC materials displayed. Across all facilities, only a small number (18%) of clients received multiple services during their visit. At UNFPA-supported integrated sites, where the service delivery model emphasizes integrated health care, only 26 percent of clients reported receiving more than one service. This suggests more emphasis may be needed on increasing awareness and understanding of integrated services within communities where these services are available. • Facilities that are practicing the UNFPA model of service integration are better at integrating services than other facilities, although room for improvement was also noted with the UNFPA model. These findings suggest that Malawi’s strong national policies and guidelines on FP-HIV integration are not ensuring that the FP needs of HIV clients are being adequately addressed in practice. A systems-level approach is needed to improve integration of FP into HIV services, such as through identifying referral mechanisms that will work for specific levels of facilities, offering more training for providers on client- oriented approaches and PIFP, equipping providers with more detailed referral options, educating clients on the availability of integrated services, improving the commodity logistics system to address stockouts, and improving routine monitoring/health management information systems (HMIS). Support for these efforts needs to come from the reproductive health (RH) and HIV departments of the MOH, rooted in a commitment to work together and in collaboration with other stakeholders, including the private sector, to improve service delivery. vii ABBREVIATIONS ANC antenatal care ART antiretroviral therapy ARV antiretroviral (drug) BLM Banja la Mtsogolo (a Marie Stopes affiliate) BTL bilateral tubal ligation CHAM Christian Health Association of Malawi CHW community health worker CMST Central Medical Store Trust DHS Demographic and Health Survey EC emergency contraception FP family planning GOM Government of Malawi HCT HIV counseling and testing HPP Health Policy Project HSA health surveillance assistant IEC information, education, and communication IPPF International Planned Parenthood Federation IUD intrauterine device LAPMs long acting and permanent methods of contraception (implants, IUDs, sterilization) MOH Ministry of Health MSH Management Sciences for Health NGO nongovernmental organization OGAC Office of the U.S. Global AIDS Coordinator OI opportunistic infection OPD outpatient department PEPFAR President’s Emergency Plan for AIDS Relief PIFP provider-initiated family planning PLHIV people living with HIV PMTCT prevention of mother-to-child transmission RH reproductive health RHD Reproductive Health Directorate SRH sexual and reproductive health SRHR sexual and reproductive health and rights viii SSDI Support for Service Delivery Integration STI sexually transmitted infection UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund USAID United States Agency for International Development WHO World Health Organization 1 Integration of services is an approach “in which health care prov iders take the opportunity to engage the client in addressing health and social needs broader than those prompting the initial health encounter” (EngenderHealth, 2014, pg. ix). This focus of integration involves provision of FP and HIV/sexually transmitted infection (STI) prevention, treatment, and care serv ices during one v isit or in one room. In addition, integration can combine different kinds of sexual and reproductive health (SRH) and HIV serv ices to improve health outcomes. Integrated serv ices do not all have to be prov ided in the same room by the same provider. They can include referrals from one serv ice to another with the aim of offering comprehensive serv ices during the same v isit (IPPF et al., 2011). The ultimate goal of integrating FP and HIV serv ices is to prov ide both serv ices under one programmatic umbrella to improve SRH outcomes (WHO, USAID and FHI, 2009). INTRODUCTION Women in Malawi have a high unmet need for family planning (FP) services; 26 percent of women ages 15–49 report wanting to space or limit their pregnancies but are not using contraception (NSO and ICF Macro, 2011). As a result, the total desired fertility rate of 4.5 children per woman is much less than the reported total fertility rate of 5.7 children per woman (NSO and ICF Macro, 2011). High unmet need for FP may be due to a lack of adequate FP services and stockouts of FP commodities. Malawi’s 2013–14 Service Provision Assessment found that 82 percent of facilities provided modern FP methods, but only 46 percent of facilities had every method available on the day of the survey (Malawi MOH and ICF International, 2014). Additionally, the quality of FP services has an impact on unmet need. A 2012 study of barriers to FP use in Malawi conducted in five districts found that “service quality and the reception provided at facilities were also seen to affect women’s access to FP services and continuance of these services” (C-Change, 2012, pp.25). Respondents in the study said that long wait times and lines were among the reasons that they had decided not to seek FP services in the past. Having received warm reception from knowledgeable staff was cited as a reason for their regularly seeking FP services (C-Change, 2012). To address Malawi’s high unmet need for FP, there is a need to improve both access to FP services and service quality. A recent report from the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that Malawi has made incredible progress in combating HIV over the past decade. New infections have dramatically declined, falling from 98,000 in 2005 to 34,000 in 2013. Malawi has also had a 67 percent reduction in children acquiring HIV, the largest country decline across sub-Saharan Africa (UNAIDS, 2014). However, Malawi is still faced with a high HIV prevalence rate and other HIV-related challenges. HIV prevalence in 2010 was 10.6 percent among adults ages 15–49, only slightly lower than the 11.8 percent reported in 2004 (NSO and ORC Macro, 2005; NSO and ICF Macro, 2011). The HIV epidemic is also highly gendered, with 12.9 percent prevalence among women ages 15–49, compared to 8.1 percent among men of the same age (NSO and ICF Macro, 2011). General studies on the contraceptive needs of HIV-positive women in Africa show that a large proportion of pregnancies (51–84%) among HIV positive women are unplanned (Wilcher et al., 2013). There is very limited research on the contraceptive needs of HIV-positive women in Malawi. One study reports an unmet need of approximately 22 percent among HIV-positive women (Habte and Namasasu, 2015). The study, which uses Malawi Demographic and Health Survey (DHS) data, confirmed high demand for contraception among women living with HIV—knowledge of their HIV-positive status was significantly associated with use of FP. The high unmet need for FP among all women in Malawi, and specifically among HIV-positive women, underscores the need to improve FP counseling and HIV testing coverage among women of childbearing age, improve access to FP services, and specifically address the FP needs of HIV-positive women. Integrating FP and HIV services is an effective service delivery approach to address these issues. Integration of Family Planning and HIV Services in Malawi 2 Globally, integrating FP into HIV services is seen as a best practice for addressing unmet need for contraception, as well as reducing mother-to-child HIV transmission. It is estimated that meeting unmet need for FP in the 20 countries with the highest HIV burden would result in six million fewer unintended births and 61,000 fewer children with HIV in the year 2015 alone (Stover and Mahy, 2011). As a result of this potential tremendous health impact, access to FP is cited as a critical component of prevention of mother-to-child transmission (PMTCT) and antiretroviral therapy (ART) programming in technical guidance issued by both the World Health Organization (WHO) and the Office of the Global AIDS Coordinator (OGAC), and is recommended as part of routine care for people living with HIV (PLHIV). The WHO recommends that services be integrated in areas with high HIV prevalence and high unmet need for FP (WHO, 2009); similarly, USAID recommends that FP and HIV services be integrated in areas with generalized epidemics, i.e. where the HIV prevalence is more than 1 percent among pregnant women (USAID, 2015). PEPFAR also requires reporting on an FP/HIV integration indicator on a yearly basis: Percentage of HIV service delivery points supported by PEPFAR that are directly providing integrated voluntary FP services. All women, including women living with HIV, have the right to decide if, when, and how they would like to start a family. Integration of FP and HIV services is an effective way for healthcare providers to ensure that these women not only have access to contraceptives, but also access to information and counseling on how to safely become pregnant if they desire, and how to do so while reducing the risk of transmitting HIV to their infants or partners (EngenderHealth, 2014; Myer, 2005). As noted in a recent report by EngenderHealth, the best way to do this, “is to offer provider-initiated FP (PIFP) as the standard for integrated service delivery, asking at least these three questions: 1. Would you like to have a child/another child? 2. When do you want a child/your next child? 3. What are you using to space births or prevent an unintended pregnancy? These measures ensure that women living with HIV are ensured the same universal human right to family planning as everyone else” (EngenderHealth, 2014, pp.3). Integration of services in Malawi Malawi has shown tremendous political support for integrating health services. Malawi is a signatory to several global calls for action that advocate for the integration of services, such as the 1994 International Conference on Population and Development (Cairo) Programme of Action, and the 2006 Maputo Plan of Action. At the national level, Malawi has issued several policies and strategies over the past decade that speak to integrating FP, sexual and reproductive health (SRH), and HIV services (Irani, Pappa, and Dindi, 2015). Likewise, donors such as USAID and the United Nations Population Fund (UNFPA) are supporting the Malawian government’s efforts to integrate FP, HIV, and other primary health services at the policy, systems, and service delivery level through projects such as USAID’s Support for Service Delivery Integration (SSDI) and UNFPA’s Linking HIV and Sexual and Reproductive Health and Rights (SRHR). The latter, for example, promotes the linkages between HIV and SRHR policies and services to better strengthen the health system in Malawi and increase access to and use of a broad range of important services. Yet, progress on the full integration of FP-HIV services in Malawi is slow. A USAID-funded 2010 study of community-based FP and HIV services in Malawi conducted by Management Sciences for Health (MSH) noted several gaps in service integration, and a second rapid assessment in 2010/2011 conducted by the Centre for Reproductive Health, in collaboration with the International Planned Parenthood Federation (IPPF), UNFPA, and others, likewise documented areas for improvement (Mtema et al., 2010; Center for Reproductive Health, 2010; IPPF et al., 2011). The assessments aimed to determine whether Introduction 3 clients accessing HIV services were able to also access FP services—either on site or through referral mechanisms. Such integration is expected to result in increased uptake of FP and HIV services, reduced cost and increased efficiency of services due to fewer hospital visits, and increased utilization of HIV counseling and testing (HCT) services among FP clients. The assessments noted several gaps and documented areas for improvement, including improving coordination between the Ministry of Health (MOH’s) Reproductive Health Directorate (RHD) and HIV/AIDS department, training providers to provide integrated services, and using task shifting to expand access to services. In 2011, Malawi issued new HIV service delivery guidelines: Clinical Management of HIV in Children and Adults. These guidelines recognize the need to prevent unwanted pregnancies regardless of HIV status, emphasize the need for dual protection, and introduce PIFP during HCT, during pre-ART follow up visits, and within ART clinics for all clients over the age of 15.1 The guidelines were subsequently updated in 2014. Yet, the extent to which these new guidelines have been implemented is unknown. Malawi also still lacks a unified national FP-HIV strategy, which could more systematically advance integration efforts in the country. In 2014, UNFPA started supporting the MOH to develop a broader SRH-HIV strategy, with finalization and dissemination planned for early 2016 (GOM, forthcoming). Within this context, the USAID Mission in Malawi requested the USAID-funded Health Policy Project (HPP) to undertake a comprehensive assessment of the status of FP-HIV integration in Malawi to improve understanding of the current state of FP-HIV integration on behalf of USAID, Government of Malawi (GOM) officials, nongovernmental organization (NGO) partners and other stakeholders, and to identify key areas for action. HPP undertook this work between August 2014 and September 2015. HPP first reviewed 19 national health-related policies and guidelines that address FP, HIV, and/or the integration of services (Irani et al., 2015), and then undertook 48 key stakeholder interviews (Irani et al., 2015a). This input provided a landscape analysis of the policy environment and current stakeholder perceptions and recommendations regarding FP-HIV integration. HPP then designed a facility-based research study to generate evidence on the extent of FP-HIV integration at the service delivery level. This study used various data collection methods to identify the key systems-level barriers to providing integrated services and captured the findings from a large sample size of key stakeholders, facilities, providers, and clients across the country. This report details the findings of this third component, with some reference to the policy review and stakeholder interviews in the discussion session. Study Objectives The overall objective of this study was to assess the extent to which FP services have been integrated into HIV services in Malawi, through different integration models and across various types of facilities (public and non-profit private [Christian Health Association of Malawi—CHAM]). The study specifically aimed to identify system-level barriers to integration, and therefore sought to look at how integration was supported through the organization of services, provider training, the commodity and logistics system, the referral system, and routine monitoring tools. The study was also designed to examine how the reproductive rights of PLHIV were being respected, safeguarded, and promoted in the context of integrated services. In particular, the researchers set out to determine whether PLHIV were being offered FP, whether they had a choice of methods within an integrated setting, what referral mechanisms existed to facilitate method choice, and, if possible, to identify any barriers to accessing FP faced by PLHIV. The study also aimed to ascertain to what extent PIFP was being implemented within ART services, as stipulated in the national ART clinical guidelines. 1 Although the guidelines notably include FP integration into ART, they emphasize dual protection of condoms and injectables, and could be improved with respect to strengthening client choice to ensure access to a wider range of contraceptive methods. Integration of Family Planning and HIV Services in Malawi 4 Health centres/posts/clinics: Primary healthcare; prov ide community health serv ices through health surveillance assistants (HSAs). Rural hospitals: In and outpatient serv ices; 200-250 beds; considered part of primary level. District hospitals: Secondary level of care; in and outpatient services; in- serv ice training; 200-300 beds. CHAM hospitals also prov ide secondary level of care. Central hospitals: Tertiary level of care with specialized serv ices; teaching hospitals; four in Malawi, of which Muzuzu is smallest with 300 beds. CHAM facilit ies: Largest nonprofit (private) health serv ices prov ider in Malawi; supported by Christian churches; operates health centres and hospitals, mostly in rural areas. The purpose of this study is to provide key practical recommendations that the MOH and other partners can implement to improve integration of FP into HIV services. METHODS This is a mixed-method descriptive case study, which involved primary qualitative and quantitative data collection. This study was conducted in 41 facilities across nine districts of Malawi (three per region) to get a broad overview of how service integration is occurring in the country. The nine participating districts (highlighted in yellow on map), which were stratified by region and then randomly selected, were Nkhata Bay, Mzimba North, and Mzimba South, in the Northern Region; Lilongwe, Mchinji, and Dedza in the Central Region; and Mangochi, Mulanje, and Blantyre in the Southern Region.2 A purposive sample of 41 facilities (public and private) was selected to represent a range of facility types and integration models. These facilities were receiving (or scheduled to receive) USAID and/or UNFPA support for integration. Facilities ranged from large, high-volume sites (rural or urban hospitals) where HIV services and FP services may be provided by different providers in different spaces (or clinics) but on the same health facility grounds (vertical services), to smaller sites (health centres) staffed by one or two providers, which clients may frequent for a variety of primary healthcare needs. Our sample of facilities included 18 health centres and one health post, nine public district/referral hospitals, seven CHAM health centres/hospitals (as these tend to provide limited FP services), and six integrated facilities where all health services are provided in an integrated manner. The full list of facilities is noted in Table 1 2 These districts were randomly-selected and not chosen based on HIV prevalence or rates of unmet need for FP. Methods 5 Table 1: List of Facilities Across Nine Districts, by Facility Type Health Center/Post (19) CHAM Mission Hospitals/Health Centers (7) District Name of facility District Name of facility Mzimba North Mpherembe Health Centre Mzimba South Mabiri Health Centre Engucwini Health Post Katete Community Hospital Thunduwike Health Centre Dedza Nkhoma Mission Hospital Mzimba South Manyamula Health Centre Bembeke Health Centre Lilongwe Lighthouse Clinic Blantyre Lumbira Health Centre Lumbadzi Health Centre Mlambe Mission Hospital Malingunde Health Centre Mulanje Mulanje Mission Hospital Mchinji Nkanda Health Centre Kochilira Health Centre Integrated Health Centers ( 6) Kapanga Health Centre District Name of facility Nkhwazi Health Centre Nkhata-Bay Mpamba Health Centre Dedza Golomoti Health Centre Mzenga Health Centre Blantyre Madziabango Health Centre Kande Health Centre Nkhata-Bay BLM Mulanje Mimosa Health Centre Dedza Ntakataka Health Centre Lujeri Health Centre Lobi Health Centre Chisitu Health Centre Mangochi Asaalam Clinic Namwera Health Centre Phirilongwe Health Centre Public Hospitals (9) Nkhata-Bay Chintheche Rural Hospital Nkhata-Bay District Hospital Mangochi Monkey-Bay Community Hospital Mangochi District Hospital Mchinji Mchinji District Hospital Dedza Dedza District Hospital Mulanje Mulanje District Hospital Mzimba North Mzuzu Central Hospital Blantyre Queen Elizabeth Central Hospital Integration of Family Planning and HIV Services in Malawi 6 Data Collection Data collection occurred between April 2015 and May 2015. In each facility, several data collection methods were employed: Facility audit The facility audit was administered by a data collector and primarily consisted of observing the counseling and treatment spaces, amount of FP or HIV-relevant supplies and commodities available on site-visit day, available information, education, and communication (IEC) materials, and presence of service delivery policies and guidelines. Surveys with staff and clients At each facility, quantitative surveys were undertaken with individuals responsible for the management of the facility (facility in-charges). Additionally, three health service providers responsible for delivering FP and/or HIV-related services were interviewed, including nurses, clinical officers, and doctors. The purpose of these interviews was to obtain an overview of the services being provided, the integration model being applied, challenges the facility might be facing, and what systems changes might be required to improve integration. On the same day, clients attending the ART clinic were invited to participate in the study. Clients first received a pre-coded form to carry throughout their visit. They recorded the times they waited at various points during their visit, the services they received, and times of contacts for each of the services. They were then requested to answer a few exit interview questions administered by a data collector. The inclusion criteria included clients who could read and write, women ages 18–49, and men ages 18–59. A purposive oversampling of women was done at each facility to better understand the needs and patterns of contraceptive use among HIV-positive patients. Based on the national prevalence of unmet need for FP of 26 percent, we calculated that 10 clients per facility would be representative of the client population in need of FP (see Annex B for calculations). Mystery clients To obtain a better understanding of client-provider interactions and referral mechanisms, nine mystery clients (three per region: two female and one male) were deployed to 20 facilities on days the data collection team was not visiting. These clients presented themselves as HIV-positive transfer patients seeking antiretrovirals (ARVs) and were trained to document whether they were spontaneously counseled and offered FP, and what happened if they wanted a method other than what was initially offered. They then followed the recommended referral mechanism. PLHIV focus group discussions To supplement mystery client data, the study undertook three focus group discussions (one per region) with a total of 32 HIV-positive clients (both men and women) participating in already-established HIV support groups. Questions were not linked to specific facilities, but rather sought to obtain the perspectives of PLHIV and their experiences with FP-HIV integrated services in their district generally. Ethical considerations The study received ethical approval from Malawi’s National Health Sciences Research Committee (NHSRC) in Lilongwe, Malawi, and the Institutional Review Board of Health Media Lab in Washington, D.C., USA. The Director of the RHD was also closely involved in the design and data collection phases of the study. Methods 7 During the facility visit, interviews were conducted in a private space and lasted under one hour (focus group discussions lasted 75–90 minutes). All participants (facility in-charge, providers, and clients) were provided details on the study in advance, and read aloud the consent form, which they then signed. No names were recorded, only titles, or in the case of clients, basic socio-demographic data. Providers and clients at the facilities were not given any compensation for their participation in this study. Participants of focus group discussions were provided with refreshments. All informed consent information and subsequent questionnaires were translated and administered in one of the prevalent local languages of the region: Chichewa, Chitumbuka, or Yao. Data entry, cleaning, and analysis Quantitative data from facilities were collected using paper data collection forms, then entered into templates developed in CSPro, then exported into STATA for analysis. Qualitative data were transcribed and then translated into English. Table 2 gives the final number of questionnaires collected across the facilities and focus group discussions. Table 2: Number of questionnaires collected, by method of data collection Method of data collection Quantity Interv iewer-administered structured quantitative facility audits, developing process maps, and observ ing client flow. 41 Interv iewer-administered semi-structured interviews with facility in-charges. 41 Interv iewer-administered semi-structured interviews with serv ice providers. 122 Self-administered client flow analyses followed by interv iewer-administered structured quantitative interv iews with clients. 425 Self-administered client flow analyses by mystery clients. 58 Interv iewer-administered semi-structured interview with mystery clients. 58 Facilitator-led FGDs with HIV-positive clients participating in HIV support groups. 3 8 A broad definition of integrated serv ices: “an approach in which health care prov iders use opportunities to engage the client in addressing broader health and social needs beyond those prompting the initial health care encounter. This includes an assessment of what health serv ice users and potential users deem to be important, of a site’s capacity, and of how the delivery systems of the core serv ice(s) will accommodate necessary changes to meet the envisioned level of integration.” EngenderHealth, 2014, pg 2. INTEGRATION MODELS This study used a broad definition of integration of FP-HIV services and found that several integration models are being implemented in Malawi’s health facilities. The most fully integrated model in use is one in which clients receive FP and HIV services in the same clinic3 or room on the same day. We defined this as “fully integrated” but allowed for this categorization to include the client being seen by different providers within the same clinic/room. UNFPA is supporting integrated health centres in 15 facilities across three districts in Malawi. These centres are dedicated to a model of fully integrated primary healthcare—a client sees one provider for all her/his SRH services. We purposefully included six of these facilities in the study as a point of comparison with other integration models. When we visited these facilities, we went to different rooms to observe the range of services provided there. The next level of integration is one relying on internal referral systems—the client is seen by different providers in different rooms or clinics, but all within the same facility on the same day. Non-integrated service delivery models included clients receiving FP and HIV services from the same facility, but on different days, or being referred to a different facility or to a pharmacy. Many facilities did not provide certain FP methods, but hosted Banja La Mtosogolo (BLM) (a Marie Stopes International affiliate) outreach services at their facility for clients interested in long-acting and permanent methods (LAPMs). In many cases, we found that facilities are using more than one model of FP-HIV service integration for a particular FP method. For instance, a facility might offer long-acting methods but also host a special BLM outreach event for administering the same methods. RESULTS 1. Facility Audits 1.1. Infrastructure (see Table A–1.1) All of the 41 facilities visited had designated clinics or rooms for HCT. Four facilities were offering ART integrated into other services, while 37 had designated clinics or rooms for ART. Two facilities did not provide FP, two integrated FP into other services, and 37 had designated FP clinics or rooms. Almost all (37) facilities had pharmacies on site. The facility audit revealed that the vast majority of facilities did provide adequate waiting areas (clean, adequate seating). However, the consultation rooms generally did not have adequate seating and lighting, although the rooms appeared to at least have auditory and visual privacy. Less than one-third (29%) of facilities had guards at the entrance to provide information/direction to patients, and about half (47%) of public health centres/posts lacked a visible sign with the name of the facility or a receptionist. Other categories of facilities fared better in this regard (50–89%). 3 In the Malawian context (and in many other developing countries), “clinic” often refers to a set of rooms (or wing) dedicated to a particular service within a larger health facility (hospital). A hospital may have an FP clinic, an antenatal care (ANC) clinic, etc. These might be permanent designations (dedicated rooms, open every day), or may rotate, with different clinics held in the same space on specific days, with signage, staffing, and supplies changing accordingly. Results 9 1.2 Availability of FP in HCT services (Table A–1.2) The facility audit found that, of the 41 HCT clinics observed, 35 (85%) had FP available at the HCT clinic. However, this was mainly due to the availability of condoms. For example, only four HCT clinics had injectables, only four had pills, and only one HCT clinic (at a CHAM hospital) offered implants. Furthermore, only nine HCT clinics (22%) had IEC materials about FP. During the facility audit, data collectors requested to see the HCT client registers to determine whether FP services provided were being documented. They were able to see the registers for 33 facilities. They found 23 of the registers had extra columns added to record whether FP counseling and methods were being provided. In three cases, a separate FP register was being maintained, and at seven clinics there was no mechanism for providers to document FP provision. 1.3 Availability of FP in ART services (Table A–1.3) Of the 41 facilities with an ART clinic or an outpatient department (OPD) room where ART services were being provided, 35 (85%) had FP available. However, as in HCT clinics, this was mainly due to the availability of condoms. Eleven of these 35 sites (31%) had injectables available within ART services, only eight had pills, five offered implants, and only two offered intrauterine devices (IUDs). Seven of the ART clinics where FP was available (20%) had a wide range of contraceptive methods available at the clinic, characterized by the presence of four or five methods consisting of short- and long-acting, hormonal and non-hormonal (data not shown). Furthermore, only 15 (37%) ART clinics had IEC materials about FP displayed. In accordance with the national Clinical Management of HIV in Children and Adults guidelines, ART service registers already contain columns to indicate whether FP counseling, condoms, and/or injectables are provided to clients. This study looked to see if there were any other columns added to the ART registers corresponding to additional FP methods. When data collectors requested to view the registers at ART clinics, half (17) were unavailable—either providers would not allow data collectors to review, the register was not yet out for the day (despite patients being seen), there was a shortage of registers at the clinic, or it was at another location (or lost/misplaced). Of the 18 registers reviewed, six had extra columns added in the ART register to document FP provision. At eight facilities where ART registers were reviewed, a separate FP register was maintained in the ART clinic, and four had no mechanism to document additional FP service provision (beyond condoms or injectables) at the ART clinic. 1.4 Availability of HIV services at FP clinics (Table A–1.4) Data collectors observed 33 facilities with FP clinics or rooms. Of the other 41 facilities, two did not provide FP and the other six had FP clinics that were not operating on the day of data collection. Twenty- five (76%) of the FP clinics offered one or more HIV services. Of those, eight (32%) offered HCT and 10 (40%) offered PMTCT. Eighteen (72%) offered other HIV services. Only 14 FP clinics had any IEC materials about HIV, and 20 had IEC materials on FP. When facility auditors checked the availability of contraceptives in FP clinics, about 30 percent did not have injectables or male condoms, 33 percent did not have pills, 45 percent did not have implants, and 64 percent did not have emergency contraception (EC). Only eight FP clinics (24%) offered IUDs and only three (9%) offered female sterilization. One facility, a public hospital, offered vasectomy. Integration of Family Planning and HIV Services in Malawi 10 Profile of facility in-charges (n=41, table A-2) • 66% are male • 44% are 30 years or younger • 51% are a paramedical worker (nurse midwife technician, medical assistant, auxiliary nurse, patient attendant, HIV counselor) • 20% are clinical officers; 17% are doctors • 42% have 2–5 years of work experience • 32% have over 11 years of work experience • 19.5% had no FP training, 7% had no HIV training • 39% had received FP/SRH/HIV integration training 2. Interviews with Facility In-charges At each of the 41 hospitals, data collectors conducted in-person interviews with the facility in-charge to determine the range of integrated services offered. 2.1 Self-reported models of integration (Table A-2.1) As discussed above, several models of integration are being implemented at health facilities in Malawi. In some facilities, FP and HIV services are offered in the same clinic or room by the same provider (or through different providers). In others, the services are offered in different clinics at the same facility on the same day. In many cases, the services are offered on different days, either at the facility or through monthly BLM outreach services. Facilities also refer out to higher-level or private facilities, particularly for LAPMs. Eight of the nine public hospitals (89%) reported being able to offer all short- and long-acting reversible methods on the same day in a different clinic/room. Five reported being able to offer tubal ligation on the same day. Only five of the CHAM facilities offered FP (two CHAM facilities were Catholic). At health centres, only about half offered injectables (10) or pills (9) in the same clinic on the same day, while eight said injectables and implants were offered in a different room, and 10 offered pills in a different room. Five facilities offered bilateral tubal ligation (BTL) and vasectomy, but on different days. Between 13 and 17 facilities, mainly the health centres, reported they also refer out or host BLM mobile services for IUDs, tubal ligation, and vasectomy. Four facilities do this for implants. In the UNFPA-supported integrated facilities (n=6), four reported that injectables and pills were available in the same room on the same day. In-charges at two facilities reported that IUDs were available in the same room on the same day. In addition, four in-charges reported that IUDs were also available in the same facility on a different day (the integration categories not being mutually exclusive). Three reported implants were available in the same room. Four in-charges also reported implants were available on the same day in a different room. Tubal ligation was only available in one facility on the same day. Three facilities coordinated with BLM outreach services for tubal ligation, and four did this for vasectomy. Almost two-thirds (63%) of facility in-charges also reported that their FP clinic is open five days a week, whereas 30 percent were open once a week, and two (7%) facilities had FP clinics open 2–4 times per week (Table A-2.2) 2.2 Community-based services (Table A–2.2) Nineteen facility in-charges reported that HIV services such as HIV monitoring, condom provision, management of opportunistic infections (OIs), and HIV-related nutrition support were provided to HIV clients in their home or community by community health workers (CHWs). Only a handful said that HCT (6) or ARV (4) services were routinely provided in this manner. Sixteen facility in-charges said that FP services were also provided to HIV clients by CHWs. The methods provided were primarily pills and condoms, although four facilities said injectables were also provided. 2.3 Stockouts (Table A–2.2) Just under half of the in-charges (44%) reported experiencing stockouts or expirations of FP commodities within the past three months, and these occurrences were mainly at public health centres. The UNFPA- Results 11 Profile of providers (n=122, table A-3) • 55% are female • 30% are 30 years or younger • 55% are a paramedical worker (nurse midwife technician, medical assistant, auxiliary nurse, patient attendant, HIV counselor) • 21% are health surveillance assistants (HSAs) • 24% have 2–5 years’ work experience; 41% have over 11 years’ work experience • 21% had no FP training, 7% had no HIV training • 24% had received FP/SRH/HIV integration training supported integrated facilities reported no stockout issues. Of the 17 facilities experiencing stockouts, two-thirds of them experienced shortages of two or more methods—primarily pills, condoms, and injectables. Two hospitals (a CHAM hospital and a public central hospital) reported stockouts of five methods in the past month. About one-third of facilities reported experiencing stockouts of HCT kits within the past three months. This is happening across all levels of facilities, but was slightly higher among public hospitals. Likewise, one-third of public health centres and hospitals experienced stockouts (or expirations) of ARVs, but the CHAM and UNFPA-supported integrated facilities did not report this difficulty. 3. Interviews with Providers Across the 41 facilities, data collectors conducted interviews with 122 providers to collect their experiences with integrating FP and HIV services. 3.1. Organization of services (Tables A–3.1 and A–3.2) Although only one-quarter of the providers reported having received FP/SRH-HIV integration training, 83 percent reported that ART services had been reorganized to accommodate the provision of FP services. This mainly consisted of onsite ART protocols being revised (42%), some providers receiving FP training (48%), and informal referral agreements being created within the facility (51%). Only 15 percent of providers said that ART service provision time was adjusted to accommodate FP, and only 11 percent reported that the ART registers had been revised. Nonetheless, the vast majority (93%) said they had time to counsel ART clients on FP. When asked what methods they counseled ART clients on, almost all mentioned male and female condoms and injectables, 83 percent mentioned pills, and 77 percent mentioned implants. Only 55 percent mentioned IUDs, 63 percent mentioned female sterilization, and 44 percent mentioned vasectomy. About 80 percent of providers said that FP services had also been reorganized to accommodate HIV services, mainly through additional provider training on HIV and referral agreements created within the facility. Just over one-third mentioned FP protocols being revised to accommodate HIV services, and just under one-third mentioned new inter-facility referral agreements being created. About 20 percent mentioned FP registers being revised. Only nine providers said that FP operating times were adjusted. 3.2. Referrals (Table A–3.3) Three-quarters of providers reported routinely referring out clients for services. However, data suggest that providers need to be equipped with more information about the referral points to which they are directing clients. Approximately two-thirds of providers knew details about the FP or HIV services they were referring for, but many lacked details on the days and times those services were available, or the transport costs to reach those services. Please see Table 3 on the next page. Integration of Family Planning and HIV Services in Malawi 12 Client profiles table (n=425, table A-4) • 78% female • 50% lower primary education • 69% married/cohabitating • 90% rural • 43% had 2–3 children; 37% had more than 4 children • Of those with HIV, 99% had disclosed to someone close, primarily a spouse or sibling/other family member. Table 3: Prior knowledge providers have of facilities to which they are referring clients for HIV or FP services (n=91) Kind of services provided Days on which services are provided Time(s) when services are provided Transport costs to reach referral site No prior knowledge of services referring for HIV serv ices 63% 54% 34% 26% 15% FP serv ices 69% 64% 44% 29% 14% Of the providers that refer clients out for services, 84 percent said there was a follow-up mechanism to confirm if clients acted on the referral. The most common way (74%) providers follow up on referrals is either to ask the client to come back to them and/or to observe records from another facility in the client’s health passport. About one-in-five providers mentioned they make follow-up phone calls and only five said they did home follow-ups. 3.3. Community engagement on integration (Table A–3.3) A large number of providers (84%) reported that the facility had informed clients and the community about integrated services. However, this mainly consisted of informing clients. Two-thirds of providers were aware of efforts to inform community groups. Only 42 percent reported that announcements were posted in the facility. 4. Clients This assessment undertook client exit interviews (n=425) at the HCT and ART clinics and conducted client flow analyses (n=425) to ascertain their experiences with integrated services. 4.1. HIV status and disclosure (Table A–4.1) Client exit interviews revealed 419 clients were HIV positive. About half (49%) of the clients had been living with HIV between one and five years, 17 percent for less than a year, and the remainder for six years or longer. Almost all (94%) had previously accessed ART services at the same facility. Almost all HIV-positive clients (99%) had disclosed their HIV status to a friend or relative. Most (70%) had disclosed to their spouse, and/or to extended family (67%). Almost 30 percent had disclosed to their children, while 32 percent had disclosed to their parents, and 35 percent had disclosed to friends. 4.2. Reproductive intentions and contraceptive use (Tables A–4.2a, A–4.2b, and A–4.2c) Of the 332 female clients interviewed, only 17 were currently pregnant. Nine (53%) of these women reported the pregnancy as mistimed (wanted to wait until later), and a further four reported it as unwanted. Of the 315 women not pregnant, 52 percent did not want any more children. An additional 14 percent wanted to wait more than two years, and another 25 percent didn’t know or were unsure when they wanted their next child. Fifty clients (16%) reported using sterilization as their permanent method of FP. Results 13 Of the total number of FP clients not pregnant and not already sterilized (n=358), 60 percent were using a method to avoid pregnancy. Half were using male condoms and one-third were using injectables. Only 11 percent were using implants, about 4 percent were using female condoms, 4 percent were using pills, and only one client (0.5%) was using an IUD. 4.3. Services received (Tables A–4.3 and A–4.4) Data collectors purposefully went to facilities on days when ART services were provided, and stationed themselves close to ART clinics for the client exit interviews. Not surprisingly, 84 percent of clients reported coming for ART services, with an additional 12 percent receiving other HIV services and only 4.5 percent receiving FP services. Only 76 clients (18%) reported receiving multiple services on that day. Even at the UNFPA-supported integrated sites, only a small number (26%) of clients reported receiving multiple services.4 Of those who did receive multiple services, 75 percent received them in the same room/clinic, with the remaining 25 percent receiving additional services elsewhere in the facility. Clients reported spending a significant amount of time traveling to the facility—almost one-third traveled between 30 and 60 minutes, but 43 percent reported traveling over one hour to reach the facility. A small number of clients (31), mostly at health centres (13) and public hospitals (10) reported not receiving the services for which they came to the facility. About half said they failed to receive services because the services were not being provided at the facility or because the client came outside the operating hours for that service. When asked about their satisfaction with services, the vast majority of clients said they were satisfied (88%), but an even larger number (97%) expressed a preference for receiving their services in a fully integrated manner (same clinic/room, same day). Of the small minority expressing dissatisfaction, half were at a public health centre, and over one-quarter were at a public hospital. The most common complaint was waiting too long. Yet, 90 percent of clients said that they would be willing to wait longer to get multiple services per visit. Over three-quarters of clients stated making fewer trips to the facility as the benefit of receiving integrated FP-HIV services, and 43 percent cited reduced travel costs as a benefit of integration. This logically corresponds with the reported travel time described above, with a significant percentage of clients having to travel over an hour to get to the facility. Less than 10 percent of clients mentioned reducing stigma as a benefit of integrating services. In client exit interviews, we asked clients who came for ART or other HIV services, “did anyone ask you if you wanted to have more children and offer you FP?” The overwhelming majority (86%) said no. 4.4. Client flow analysis (Table A–4.5) Our efforts to document client flows through the health facility showed a significant range in wait times and time spent with providers. In health centres/posts, the time spent in the ART waiting room and ART registration averaged over one hour, but ranged from as little as 0 minutes to as much as 351 minutes (almost six hours). Average wait times at public hospitals were similar, with a maximum reported wait time of 230 minutes. Time spent with ART providers averaged roughly 10–15 minutes. Average wait time was slightly higher at CHAM facilities, but so was time spent with the provider (an average of 20 minutes). The UNFPA integrated sites had wait times similar to public health centres, but lower average client-provider interaction times. Only 17 clients from six facilities reported going to an FP provider/clinic after their ART services. For these individuals, this added between one and 26 minutes to their visit. 4 This is substantially lower than findings from a recent MEASURE study on integration that found 65 percent of ANC clients, and 42 percent of under-5 clients received additional services on the day of their visit (MEASURE Evaluation, 2015). Integration of Family Planning and HIV Services in Malawi 14 4.5. Provider-initiated Family Planning (Tables A–4.2b, A–4.3), As part of the research design, we specifically wanted to ascertain to what extent PIFP was being implemented in ART clinics as stipulated in the national clinical guidelines. In our exit interviews with 425 clients seeking health services, we began this line of questioning by first identifying the number of clients who were potential FP clients (not pregnant, not already sterilized)—358 clients. We asked these clients whether a health provider at the ART clinic had ever inquired about their fertility intentions. Twenty-two percent said yes, 39 percent said no, and 39 percent gave no response. Among the different types of facilities, the clients attending the UNFPA-supported integrated health facilities reported the highest positive response to this question (40%). Whereas only 20 percent of clients at public health facilities and 21 percent of clients at public hospitals said yes, only 11 percent of CHAM clients said yes. We then tried to ascertain how often clients recalled having received counseling (every time, often, sometimes, rarely, or never). Of the 78 clients who reported receiving FP counseling at the ART clinic, 19 percent said they receive counseling every time, a further 30 percent said “often”, 16 percent said “sometimes”, one-third said “rarely”, and only one said “never” (See Figure 1). During another line of questioning, we specifically asked clients who had come for ART (n=355) and other HIV services (n=51) if any health provider had asked them about their fertility intentions and/or offered them FP during their visit that day. Only 56 (14%) said yes (See Figure 1, Table A–4.3). Figure 1. Prevalence of provider-initiated family planning among clients accessing HIV services on day of facility visit 5. Mystery Clients Using mystery clients is a valuable approach to obtaining information on client-provider interactions (Boyce and Neale, 2006). It allows researchers to test how services are provided given certain client profiles, minimize recall or other biases in self-reporting through interviews, and reduces the “Hawthorne Effect”—that data collectors undertaking observational assessments may influence provider and client interactions merely by their presence. Therefore, this study also sought to conduct mystery client visits in 22% 14% 33% 16% 30% 19% 0% 20% 40% 60% 80% 100% Has the provider at the ART clinic ever inquired about your fertility intentions and counseled you on FP? (n=358) At the ART clinic, how often has the provider counseled you on FP? (n=78) Did anyone ask if you today if you wanted to have more children and offer you family planning? (n=406) Yes Rarely Sometimes Often Every time Results 15 Nine mystery clients: • Female 20, 23, 24, 30, 34, and 36 years of age. • Male 19, 33, and 35 years of age Twenty facilities visited: • Mzuzu Central Hospital • Thunduwike Health Centre • Nkhoma Mission Hospital • Mchinji District Hospital • Nkhwazi Health Centre • Dedza District Hospital • Malingunde Health Centre • Lobi Health Centre • Bembeke Health Centre • Mzenga Health Centre • Mulanje Mission Hospital • Lujeri Health Centre • Mulanje District Hospital • Mlambe Mission Hospital • Queen Elizabeth Central Hospital • Mangochi District Hospital • Monkey-Bay Community Hospital • Mpamba Health Centre • Nkhata-Bay District Hospital • Engucwini Health Post a subset of the facilities. Nine individuals made 58 mystery client visits to 20 facilities across all three regions. All mystery clients were HIV-positive patients who were on ARVs at other facilities. The mystery clients presented themselves as ART clients temporarily in the area and in need of ARV resupply (e.g., visiting a sick relative, husband just transferred, etc.). Six of the mystery clients were women between the ages of 20 and 36 years; three were men between 19 and 34 years of age. The mystery clients were trained to first see whether providers mentioned FP, and if not, to ask about it. They were provided with suggestions for different profiles or scenarios regarding their reproductive intentions. For example, the older females said they had three or four children and didn’t want any more, whereas younger females were told to say they had one child and wanted to space their births. The 19-year-old male presented himself as a student.5 5.1. Services received Mystery clients had variable experiences with receiving FP services when they went to get their ARVs. Fewer than half (25) of the mystery client visits were reported to have resulted in a satisfactory experience. At one of the district hospitals, mystery clients reported that ARVs and FP methods were available but that they would need to pay for the FP methods. One additional mystery client reported that, while he did receive FP services, these services were not comprehensive, as he received resistance from providers in the provision of FP services and was ultimately only offered condoms. Another finding from mystery client visits was the infrequency of PIFP. Only two of the mystery clients reported that the provider had proactively brought up the topic or asked them about FP, rather than the client having to ask after receiving their ARVs. These experiences were quite pleasant: “She [the provider] said “all of [the choices] are present and added it was my choice to choose which one I prefer.” ~Female, 36, district hospital “She [the provider] noted my book had nothing on family planning and started advising me of FP an all methods like vasectomy, Norplant, IUCD…she later advised me to opt for a family planning method to avoid unwanted pregnancy.” ~Female, 20, health centre 5.2. Mistreatment of clients An unanticipated finding of the mystery client visits was the existence of a surprising amount of provider harshness, mistreatment, and abuse of clients. Eleven mystery client visits (19%) reported providers being 5 The mystery clients did have the flexibility to change their stories slightly as the situation required. For instance, the 19-year-old male presented himself first as married, but when further questioned, admitted to being unmarried. In another instance, one facility had no clients, so the two mystery clients presented as a married couple. The research team (with knowledge of the MOH) created temporary health passports for the clients to support their profile. Any ARVs collected by the clients were documented and returned to the health system via the Lighthouse Clinic in Lilongwe. Integration of Family Planning and HIV Services in Malawi 16 unfriendly, harsh, and even yelling at the client. They reported needing to “plead” to get ARV services, and a few said they were threatened. One mystery client left before seeing the provider at one of the health centres after receiving a text from the previous mystery clients about their negative experiences. “[The nurse] called me a beggar.” ~Female, 34, central hospital “I persisted and he left me in the room and went out. I stayed for a long time and when he came back I was told that I should go and should I continue persisting I will be beaten.” ~Female, 24, health centre Clients also experience similar troubles when asking about FP services. The young male mystery client (19) reported not being taken seriously at two facilities when he asked about FP, and was only offered condoms. “I then asked for family planning to which he responded how come I wanted family planning when I was in school”[provider offered FP options and information, but laughed at him] ~Male, 19, health centre Another health centre fared particularly poorly in their interaction with the mystery clients. The two quotes below are from the same location. “When I asked him [the provider] about family planning he shouted at me saying the room was not for family planning: “had it been that you are looking for family planning you could have gone to the family planning room. Go out, I want to assist other patients please.” I ask him about condoms. He said I am wasting his time there was no condoms.” ~Male 33, health centre “Then I asked about family planning and I was told that I should not delay him he has a lot of work to do and he sent me away. He said that if I want family planning methods I should come the following day around 8 a.m.” ~Female 24, health centre 5.3 Challenges to the methodology One limitation that our mystery clients faced is that several health facilities were not receptive to treating ad hoc or “emergency” clients. There were three health centres/posts (five mystery client visits) where mystery clients reported that the facility refused to provide ARVs because the client was not registered at that clinic; clients were told to go back to their own facility: “[I was told] ‘Your problem has been heard but our policies here are that we give emergency ARVs to one person per week meaning that four people per month. Since we’ve already given to someone else, we will not give you drugs. I suggest you go somewhere else or try your best to go back and explain your story so that they help you.’” ~Male, 33, health post Apart from this, during five other mystery client visits at five separate facilities, while the clients were not outright refused ARVs, they reported difficulty receiving services or resistance on the part of the provider to helping them. One client recalled an experience in which “emergency,” non-regular clients were asked to come forward and were then told “that due to congestions we should come again tomorrow for special ART.” Additionally, during four other visits, mystery clients reported that providers seemed suspicious of their health passport and/or story, which may have affected their experience. Eleven mystery client visits at seven different facilities resulted in similar responses when clients asked about FP services. The mystery clients were told that they could not receive these services since they were Results 17 not registered as regular clients at the facility. During one of these 11 visits, the client was even told that she could not get services there because she was not registered but if “desperate” she could go seek them at BLM. 6. Focus Group Discussions Three focus group discussions with HIV-positive clients (n=33) were included in the design of this study. Participants were recruited from existing HIV support groups affiliated with three district hospitals that provide ART—one in each region. Participants were asked a range of questions regarding their experience with HIV health services. 6.1. Organization of services Focus group participants noted several challenges in receiving ART, as well as integrated services, at facilities. Key issues that were raised include: • Clients arriving early in the morning to the clinic but providers not starting to see patients until 11 a.m.; • Facilities being overwhelmed on days when the town market is open for business and vendors come from far away to sell their goods; • Rooms/clinics not being big enough for multiple services; • The length of time to obtain one service sometimes meant that the other clinic was closing by the time clients sought the other service; and • The fact that the timing of ARV resupply (one or two months) and the most popular FP method, the Depo injection (quarterly), do not easily coincide. Focus group participants were asked about how they would like to receive health services, and their opinions about various models of integration. Several participants commented that receiving services the same day would be convenient with respect to travel and wait times. “I think it can be better to get this service at the same time because we come from different places so it is not easy to make time and come for the other service because you may get unforeseen problems. So if it was done on the same day it can be helpful than to come on different days.” ~Female HIV-positive client However, feedback varied on whether services should be fully integrated (same day, same room, same provider). Participants noted that (due to wait times) sometimes by the time they finished with one service and went to the other clinic, it would be closed. In these cases, they felt receiving services on separate days was acceptable, as long as these days/times were known and predictable. For instance, some mentioned that they may come to the facility and then be told FP services are closed or not available. 6.2. HIV services Issues of privacy and comfort with integrated services also came up in the discussions. Many patients spoke of HIV-related stigma and discrimination and said they were more comfortable talking with their HIV service providers than with FP providers. “If we got both in one place it could be good because we are usually very open to talk about our health issues to the providers in ART department, and to connect with the different person at family planning is not easy.” ~Male HIV-positive client 18 “The problem is some of us getting ARTs are very sick and can’t control our bowels when one has diarrhea and people laugh at you when that happens, so we must not be mixed on the same queue with ordinary outpatients.” ~Male HIV-positive client The question of stockouts was asked of the focus group participants, and many said stockouts were an ongoing problem and that they had experienced being unable to get ARVs at health facilities. Also, concerns regarding inappropriate dispensing of ARVs and/or fraudulent accumulation of drugs for selling on the open market were commonly discussed. “The issue of selling ARTs was spoken about the other day I went to the clinic. They said there are some people who may come to the clinic and lie that I am travelling maybe to South Africa and need to get doses for a long time, and they may get six bottles then they go maybe to Chintheche and lie there again and get another six bottles, and so on. Then they put those ARTs together and start selling. So this also affect us because there comes a shortage of drugs.” ~HIV-positive client “It is true that the government must take action on this, we have a problem here, some say the ARTs are used in other inappropriate ways, some say they use it for fishing Usipa, others say so many other things, but the problem comes to us who are using the drug, because we sometimes come and find there is no drugs and you are told to come next week yet your ARTs are finished. And if you beg them to give you even just a little because you have nothing they shout at you. So please the government must take part in this.” ~Female HIV-positive client One focus group participant who attends a district hospital complained about the quality of HIV services. His comments echoed the experience of a mystery client visit, thus suggesting that facility may need some quality improvement interventions. “When we get to [the district hospital] we don’t get weighed on the scale nor are we checked for our CD4 count, so we only take the drugs without checking how we are doing. It could have been better if we were told about how we are doing as we take the drugs.” ~Male HIV-positive client 6.3. FP services Facilitators asked the focus group participants whether health providers had talked to them about family planning, and specifically, about PIFP. Responses varied. Some participants said that providers had never talked to them about FP, but others said that they had. “I get my ART at the district hospital, and there when I get the ARVs they also ask if I would like condoms, and if I want them, they give them to me. So I get the condoms from another room right inside the ART department.” ~Female HIV-positive client “Nurses there can ask to have the husband come first to sign for the woman to get a method, now you go tell your husband and he refuses to come with you because he doesn’t want you to do it. Some claim they get back pain when they have sex with the wife using the family planning methods. So the woman does it without his consent and when he finds out about it he may go to the hospital and shout at the nurses in family planning department as to why they allowed his wife to get the methods. That scares the nurses, and they send back women whose husbands don’t come. So if there were agreements made in the home about family planning it could be better.” ~Female HIV-positive client Results 19 There were some concerning comments during one of the group discussions in which a few participants talked about BTL failures. The conclusion these participants had was that these procedures were “temporary BTLs.” Since BTL is a permanent procedure, and failures are extremely rare, these findings raise concerns as to what could be occurring (such as provider error, community misconceptions, etc.). “I also know two people who did it [BTL] and yet still got pregnant. There is a relative of mine that did BTL and yet fell pregnant. So what I saw to be happening is that maybe they see that the client is still young then they decide to just let the woman have a break of maybe five years, and not really completely do a BTL. Because when you come for such a procedure they ask how many children you have and you say “two”, how old you are you say “fourteen” so they see you have a long way to go and do a temporary BTL. I wish they could just do as the one who wants it done has said and not make decisions for them.” ~Male HIV-positive client 6.4. Provider shortages and task sharing The focus group participants were acutely aware of the stress the health facilities and the existing providers are under, due to high demand for services. Several mentioned staffing shortages as a barrier to integrating services. “… the reason for that is because there is not enough medical staff. The ones that help dispense drugs are not really assigned to do it, they only do it to help and they have their own work to do. For example the patient attendants, dispensing drugs is not their job. So they also have too much work because of that. And even the nurses are not enough here, you find that the same nurse is working at antenatal, and also at the labor ward and she is also supposed to be here giving out drugs which is too much for one person to do. In the end, they just send anyone, even one who is not qualified to do the drug dispensing, and yet that one also has their own work to do. So in the end they don’t do a good job. So if they were to say twice a week for HIV services it cannot work.” ~Female HIV-positive client “…sometimes, where we get ARTs, the provider is alone dispensing drugs and cannot have time to also give family planning, but if there would be more providers where we get ARTs, others doing ARTs and the other family planning it can work. One person cannot do both things alone, because we are many.” ~Female HIV-positive client “I think if there were enough health workers, it is possible to give both services at the same time and same place. It happens the way it does because there is not enough staff.” ~Female HIV-positive client Some expressed concern regarding the delegation of tasks and how this might be impacting clients’ health. “The main problem at [the local] hospital is we rarely find the clinical officer on duty. We mostly find those who help in dispensing drugs and these people don’t understand anything about what a person is suffering from. They just know about giving the drugs, so this is not right for our health.” ~Male HIV-positive client Integration of Family Planning and HIV Services in Malawi 20 6.5. Mistreatment of clients Similar to the findings from the mystery client data, the focus group discussions revealed that some clients experience mistreatment from service providers. Participants reported being shouted at, spoken to rudely, and being “punished” (chastised) by providers. In some cases this may be the behavior of one provider, who is overworked: “It is true, there is one clinician, but she shouts at patients anyhow. It even happened to me she almost sent me back without my drugs. I think she does that because there are too many people she has to attend to.” ~Female HIV-positive client But another participant’s input indicated it was a more systemic issue: “One problem that we have is sometimes the dates of our visits here, and maybe you have a problem on that day and couldn’t come, and you come maybe the following day. We get punished by not being given the medicine on time. They make us wait until late afternoon to get the medicine, so we live far from here and we get home late in the evening. So we try to ask the nurses to consider that, but they don’t do anything about it…We think it must be a rule made by the facility management, because it is not a single person who does this. They can be a group of them together saying “you were supposed to be here yesterday,” so they put you aside and attend to you when they are done with everyone else later. So that is one problem at the health facility that most of us encounter…I get mine at X hospital, so we sleep at the hospital so that the following day we get the medicine, because if you miss it you will be punished. We find it difficult to get transport money to use when we are to come here for our medicine, so we have to come the day before to avoid being punished in case we don’t get that transport money on time.” ~Male HIV-positive client 21 DISCUSSION Integration of health services is an increasingly important issue being studied and addressed by researchers. Evidence from such studies shows that integration is feasible and acceptable (Liambila et al., 2008; Kennedy et al., 2012; Atun et al., 2011; Shigayeva et al., 2010; Kuhlmann, Gavin, and Galavotti, 2010; Ethiopia Federal Ministry of Health, 2007; NASCOP, ND; Kolker, 2008; White, 2009; Blaya, Fraser, and Holt, 2010). The studies further show that integrating health services results in better access to services and improved health outcomes. However, evidence also suggests that weaknesses within the health system have an impact on the quality of integrated services (Reynolds and Sutherland, 2013). Hence, to benefit fully from integrated services, there is a need to strengthen several health systems components, such as policies, financing, supply chains, human resource capacity, laboratory systems, management and supervision systems, and behavior change communications (Travis et al., 2004; WHO, UNAIDS, and UNICEF, 2011; Sitienei, 2011; UNAIDS, 2010). Over the past decade, Malawi has made political and programmatic commitments to integrating FP and HIV services. A recent review of national-level policies revealed extensive mention of FP and HIV integration in various policies and guidelines (Irani et al., 2015). This study was designed to look at how these policies and guidelines were being implemented in practice. To collect data, a cross section of facilities was visited to identify barriers to FP-HIV integration at different service delivery points. However, this cross section was not a representative sample of all facilities in Malawi. Data from this study suggest that there are several programmatic areas that require significant effort and investment if Malawi is to realize the public health benefits of service integration. Extent of FP-HIV Integration This mixed method facility-based assessment found multiple models and approaches to integration being implemented at health centres and hospitals throughout Malawi. Many facilities seem to employ more than one model of integration—with some FP and HIV services being offered in the same room by the same provider, and other services being offered on the same day but with a different provider or in a different room. However, current efforts to integrate FP into ART services seem limited to condoms, and, to a lesser extent, injectables. In many cases, clients seeking LAPMs are referred elsewhere or told to wait until the next BLM outreach event. Several service delivery pressures affect the organization of services and the extent of integration. Issues of physical space, privacy, and a lack of providers affect whether and how facilities provide integrated services. Clinic hours of operation and provider availability seem to be hindering service provision in facilities relying on internal referrals (referring ART clients to the FP clinic at the same facility for same- day services). Comments from clients raised this issue. For instance, some described arriving at a facility at 8 or 9 a.m., but providers not starting services until 11 a.m. Others described finishing with ART services and moving to the FP clinic only to find it had closed for the day, sometimes earlier than the posted hours of operation. Some comments from the focus group discussions also indicated client concerns that task shifting to health surveillance assistants (HSAs) and other cadres to deal with high client loads was devolving into drugs being dispensed without adherence to other routine monitoring recommended for HIV-positive clients (such as recording weight, periodic testing of CD4 levels, etc.). Since the effectiveness of integrated services depends significantly on the quality of provider-client interaction, the overall health system will need to better address human resources for health issues to successfully advance integrated services. Likewise, the monitoring and evaluation and commodity logistics systems need further investment to accommodate integrated services. Multiple registers were observed at many HCT and ART clinics, complicating paperwork for providers. Additionally, several facilities seemed to have no system to Integration of Family Planning and HIV Services in Malawi 22 document provision of or referral for FP beyond condoms and injectables (no additional columns, no separate FP register). A comprehensive system for monitoring integrated services would be very helpful—such as having a common register for HCT, ART, and FP services. This would enable all services to be provided in one room by the same provider, and would eliminate the need to record the same client in multiple registers. There also needs to be space in the register to record referrals, with clear notes in both the register and the patient card for following up with the client upon their return. In addition, providing HCT test kits and all FP and ART commodities in one room would equip providers to provide prompt integrated services. Demand for Integrated Services In the client exit interviews, and through the focus group discussions, clients expressed a significant interest in receiving integrated services. Even though clients already feel the wait time at facilities is burdensome, almost all said they would be willing to wait longer to receive multiple services. Reduced trips to the facility and reduced transportation costs were the two biggest benefits clients cited, suggesting that these financial and opportunity costs of seeking care may be more onerous than managers of the health system realize. However, there also may be a need to educate clients about opportunities to receive integrated services. Client exit interviews revealed that only 18 percent of clients received multiple services on the day they visited the facility. This only increased to 26 percent at the UNFPA-supported sites, whose mandate is specifically to provide integrated services. This suggests that many factors, such as provider attitudes, integrated supplies, etc., together determine whether clients receive integrated services. Likewise, facility audits revealed a lack of IEC materials, and less than half of providers said notices on integrated services were posted in facilities. A move towards integrated services needs to focus not only on a reorganization of services at the facility and improved provider training, but also on raising awareness and changing mindsets and expectations about the availability of multiple services through increased client and community education and demand creation. Education sessions during facility visits can also be ramped up to encourage clients to request multiple services when they visit facilities for their ART needs. More research is needed to ascertain how integrated services may or may not cultivate a supportive environment for HIV-positive clients. The potential for integrated services to reduce stigma and discrimination did not figure prominently in the exit interviews. Reduced stigma and discrimination was listed as a potential benefit of integration by only 10 percent of clients. However stigma and discrimination was a prominent theme in focus group discussions. Some HIV-positive clients expressed a preference for waiting among other HIV-positive clients and seeing HIV service providers. These individuals felt they would receive more empathy and acceptance from their peers and from knowledgeable service providers than if they were in queues with “ordinary outpatients.” Availability of Contraceptives and Method Choice One impetus for this research study was USAID’s desire to assess whether HIV clients had access to a range of voluntary contraception to meet their reproductive intentions. National ART clinical guidelines promote integration of FP into ART services—stating that all clients age 15 years and above should be counseled on FP and that ART providers should be offering clients condoms and injectables, and giving referrals for other FP methods. What is clear from the facility audit data (See Section 1) and the provider and in-charge interviews (See Sections 2 and 3) is that the availability of FP commodities and method choice remain limited. Few facilities had a range of FP methods available for either FP or HIV clients. The facility audit revealed HCT and ART clinics are largely relying on condoms, and fewer than one-third of ART sites had injectables available, as required by national guidelines. Furthermore, only 20 percent of facilities had Discussion 23 what the authors would describe as a substantial method choice (a range of short-acting, long-acting, hormonal, and non-hormonal methods). Likewise, only about one-third of ART clinics had FP-related IEC materials displayed. Interviews with facility in-charges and providers at health centres did not present a drastically different picture. Only about half of the in-charges reported pills, injectables, and implants were available the same day. They also reported that stockouts of commodities continue to be a major issue for almost half of the facilities, and likely contribute significantly to a lack of method options. The facility audit found almost one-third of FP clinics did not have short-acting methods. Higher-level managers of the public health system may not be aware of the degree to which method availability and method choice is a problem. For instance, public hospital in-charges seemed to overstate the availability of FP at their facilities. Although eight out of nine hospitals reported being able to offer all short- and long-acting reversible methods the same day, the facility audit found only four of the nine hospitals had IUDs at the FP clinic, and only five had implants. Stakeholder interviews conducted prior to this facility assessment (Irani et al., 2015a) found that several national-level stakeholders believed that condoms and injectables were more readily available and integrated into ART services than we observed in this facility assessment. These findings suggest that monitoring and reporting systems are unable to identify and correct issues of commodity availability. Additionally, more commitment is needed throughout the health system to ensure that ART clients have access to a full range of FP methods. Since over half of the HIV-positive women presenting for ART services did not want any more children, LAPMs in particular should be better integrated into ART services. Current State of Referrals A vast majority of providers (93%) reported that they had time to counsel ART clients on FP, and three- quarters of providers reported routinely referring clients for other services. Yet, of the 425 clients interviewed, only two reported being referred for other services to other facilities. Mystery clients also reported that they were only counseled on FP at their own instigation, and were not often given information regarding where and when to access referral services, or the potential cost of services. Poorly functioning referrals were also identified as a challenge by a recent study on integrated services in antenatal care (ANC) and under-five clinics in Malawi (MEASURE Evaluation, 2015). Provider-initiated Family Planning (PIFP) A key objective of this study was to ascertain to what extent PIFP was being implemented in ART services. We captured clients’ experiences on this issue through three data collection methodologies: client exit interviews, mystery clients, and focus group discussions. In exit interviews, we asked about PIFP in several ways. We asked clients whether providers at ART clinics ever counseled them on FP, how often these providers counsel them on FP (ranging from every time to never), whether the providers ever inquired about fertility intentions or FP, and whether a provider had discussed FP with them at the current visit. Only 22 percent of clients reported ever being asked about fertility intentions or FP at the ART clinic, and only 14 percent reported being asked during the current visit. The focus group discussions did not shed much additional light on whether clients are receiving PIFP. Some participants reported that providers did initiate conversations with them about their fertility intentions or asked if they wanted condoms; others said that their provider had never talked to them about FP. However, mystery client visits confirmed extremely low implementation of PIFP. These findings reported by clients stood in stark contrast with provider interviews. The vast majority (93%) of providers said they had time to counsel ART clients on FP. This calls for further investigation into the challenges providers face in initiating FP counseling, such as time constraints and lack of Integration of Family Planning and HIV Services in Malawi 24 training, accountability, and incentives; and for finding ways to strengthen this critical component of service delivery. Furthermore, providers need to be counseling HIV-positive clients on a full range of FP methods. ART providers seem to focus largely on male and female condoms and injectables. While over three-quarters of the providers reported counseling on pills or implants, fewer mentioned female sterilization (63%), IUDs (55%), or vasectomy (44%). Finally, more emphasis should be placed on PIFP discussions with male ART clients. ART clinics are primarily relying on condoms as their approach to integrating FP into ART, but this is particularly true for male clients. In an effort to encourage male involvement and couples’ decisionmaking, providers can pose leading questions to male ART clients to inquire about their fertility intentions with their partner and introduce options for the male client to discuss with his partner at home, including vasectomy. Respectful Care Mystery clients and focus group participants described instances in which health providers shouted, chastised, or otherwise mistreated clients, raising important questions about the quality of health services and respectful care. Some focus group discussion participants reported simply receiving ARVs, without having their status (weight, CD4 count) monitored. While this study was not specifically designed to investigate respectful care, these accounts are cause for concern and worthy of further investigation and interventions. We encourage more research using mystery client methodologies to explore this issue. Public vs. CHAM vs. UNFPA-supported Sites The study included sites that are managed by the public sector and CHAM (religious-affiliated private sector). It also included some public facilities that are part of a UNFPA-supported pilot effort to offer fully-integrated services. This allowed exploration of how national policies and guidelines on integration are being implemented across sectors. The UNFPA model of service integration did seem to be better at integrating FP and ART services, but primarily for short-acting methods. Client access to LAPMs through integrated services was still quite limited. In addition, appropriate referrals for LAPMs were not being carried out. The UNFPA-supported sites also did not report difficulties with stockouts of contraceptives, HCT kits, or ARVs, showing that both the organization of services and the logistics systems were supporting FP-HIV integration. Likewise, provider training on integration was probably stronger and more client-focused at UNFPA sites, as significantly more clients (40%) at UNFPA sites reported that ART providers inquired about their fertility intentions. Nonetheless, there remains room to improve full implementation of PIFP, as well as access to LAPMs. One finding was surprising, given the integrated model. Wait times for clients at UNFPA sites were similar to other public facilities, but average time spent with the provider was lower, whereas one may have hypothesized the opposite. This is perhaps worthy of further study. Likewise, despite these sites being specifically organized to promote integrated services, only one-quarter of clients emerging from the UNFPA sites reported receiving multiple services that day. This may indicate a need for more community outreach and client education to increase demand for integrated services. CHAM facilities are managed privately and, due to religious objections, two out of seven CHAM facilities did not provide FP. The remaining five CHAM facilities still had some weaknesses in relation to integrating FP and HIV services. Only two facilities had injectables available at the ART clinic (as required by national ART clinical guidelines), and CHAM facilities had the lowest percentage of clients reporting that ART providers initiated discussion about their reproductive intentions (PIFP). For those CHAM facilities that reported providing FP in a different room/clinic, there was still heavy reliance on referring out and/or BLM for LAPMs. CHAM facilities seemed to struggle with contraceptive and HCT kit stockouts similar to their public sector counterparts, but none reported ARV stockouts. Wait times at CHAM facilities seemed to be higher, but clients also reported spending more time with providers. Recommendations 25 Other Issues for Further Investigation During data collection, some instances of a lack of adherence to common professional standards were observed. For example, providers not wearing white uniforms or having IDs, making it hard to identify them as health workers; providers announcing patient information loudly or speaking openly, jeopardizing clients’ right to privacy; clinics being set up in ways not conducive to proper counseling; and facilities not observing posted clinic hours (opening late, closing early). These observations suggest a lack of supervision and motivation—issues that warrant follow-up. We were also surprised to hear comments about BTL failures in focus group discussions. Given the high number of women in Malawi relying on BTL, these comments may warrant additional exploration to ensure that procedures are being done properly and community myths or rumors are not negatively impacting the image of female sterilization. RECOMMENDATIONS This study suggests that, while several models of FP-HIV integration are being implemented in Malawi, the MOH needs to strengthen the health system to support facilities in identifying the best ways to integrate services. Clear recommendations are provided below. • Referral mechanisms—internal, parallel, and external—are in significant need of improvement: o Providers should have more detailed information on a variety of referral points (public and private) for each FP method, including the days and times referral services are available and distances to facilities. Providers should not exclusively rely on referring clients to BLM outreach events. These events may be a month away, during which time, clients are at risk of an unplanned pregnancy. Providers should also be aware of neighboring facilities (public and private) offering FP services—particularly LAPMs—that a client can access immediately/sooner. o At larger facilities, where same-day internal referrals are an option, ART providers should be more proactive in referring clients to the FP clinic. However, facilities need to think creatively about how to handle such internal referrals. If ART clients are sent to the back of the FP queue after having already spent several hours at the ART clinic, they may have to spend all day at the facility, and may leave without receiving FP services. Facilities with multiple providers may want to explore dedicating an FP provider to specifically seeing ART clients. This provider could then be deployed to serve elsewhere when there are no ART clients waiting. o The MOH should put mechanisms in place to ensure that providers and facility in-charges adhere to facility opening and closing hours, so that clients can plan their visits and access all needed services. • Although PIFP has been included in Malawi’s ART clinical guidelines, full implementation of the guidelines requires targeted systems changes. Providers need more and better PIFP training, and facility in-charges need to be held accountable to measurable PIFP indicators. Specifically, there is a need for improved tracking and reporting of FP commodities and services provided through ART services, as well as improvements in documenting referrals. • Facilities should complement health systems changes with improved community education on opportunities for integrated services. More IEC materials and notices should be posted within facilities and communities to increase clients’ awareness of integrated services, times and locations of services, etc. In addition, providing education sessions while patients wait for Integration of Family Planning and HIV Services in Malawi 26 services could help inform and engage clients on the availability and benefits of integrated services. • Commodity availability is a key component of providing integrated services. Facilities should take regular, detailed stock of condoms, injectables, and other FP methods in addition to ART- related dugs and commodities. Such stock-taking requires close coordination between ART and FP clinics within facilities. Better planning and communication at the clinic and facility level is key to addressing commodity stockouts. Also, more prompt requests for commodities should be made by facilities to the central government. In addition, there is a need for better coordination between the MOH’s RHD and the HIV departments to ensure the availability of commodities at both FP and HIV clinics. The central government needs to identify which logistics method will be used to distribute commodities, as many parallel systems exist through the HIV department, USAID Deliver, and Central Medical Stores Trust (CMST). Several countries in sub-Saharan Africa have successfully tested and applied logistics systems models, which Malawi could apply and learn from. For example, Tanzania has established a “pull” system through a revised digital logistics management information system, which has resulted in better distribution times and fewer stockouts. As a long-term vision, digitization of health services/patient files will make a significant contribution to patient management and monitoring and evaluation for integrated services. • More attention should be paid to the working hours of facilities and provider workdays. Facilities need better scheduling systems, and providers need better accountability mechanisms to ensure a full and productive workday. If clinics remain open to the end of the day, referred clients from other clinics will be able to access services on the same day. Further enhancement of task shifting approaches may help. Malawi may also want to explore policies that may better accommodate providers seeking to work in both public facilities and private clinics. For example, Tanzania has created a policy allowing providers to see private clients at public facilities during specific times. In Malawi, a similar approach is being tried in large hospitals in major urban areas, but may need to be expanded to smaller facilities. Some analysis has shown that offering private services in public hospitals at certain times of day (after seeing public patients) can both generate substantial income for the public healthcare system and improve services by retaining health workers and providing them with a supplemental income, improving infrastructure, and ensuring a better supply of commodities (Chilongani, 2003). • The RHD and the HIV department of the MOH should consider joint supportive supervision visits to facilities to improve their coordination and joint oversight of programs. • The MOH needs to work more closely with CHAM facilities to ensure that these facilities are properly implementing national policies and guidelines and actively contributing to health monitoring systems. At this time, CHAM facilities are not required to share their monitoring reports on clients seen and services dispensed. The MOH needs to strengthen its monitoring system and expand it to CHAM facilities, enabling the government to get a better sense of the services patients are accessing and the needs of the community. • Additional research is needed on the quality of health services in Malawi and barriers to respectful care. This should be complemented with research on provider training, attitudes, and work demands/stress levels, as factors that may contribute to poor quality care. 27 CONCLUSION This study noted that several significant efforts are being made to integrate FP into HIV services across Malawi. The type of integration and the extent to which it has been successful have depended on several health systems characteristics, such as facility type, provider training, availability of ARVs and FP methods, and current state of referrals. Condoms are the primary contraceptive method available at ART clinics, and although national guidelines call for ART clinics to offer injectables, less than one-third of ART clinics have injectables on site. In addition, only about one-fifth of clients reported having ever been asked about their FP needs while at the ART clinic, despite the fact that over half of clients reported not wanting any more children. To compound this, the majority of hospital in-charges are not aware of the shortage of FP methods in their facilities, as is made clear in the discrepancy between what they in- charges stated in interviews and the findings of the facility audit. When clients do ask for FP on their own accord, most health centres refer them to other facilities or BLM outreach for LAPMs, while larger facilities refer clients to the FP clinic in the same facility. Facilities that are practicing the UNFPA model of service integration are better at integrating services than other facilities, although room for improvement was also noted with the UNFPA model. These findings suggest that Malawi’s strong national policies and guidelines on FP-HIV integration are not ensuring that the FP needs of HIV clients are being adequately addressed in practice. A systems-level approach is needed to improve integration of FP into HIV services, such as through identifying referral mechanisms that will work for specific levels of facilities, offering providers more training on client- oriented approaches and PIFP, equipping providers with more detailed referral options, educating clients on the availability of integrated services, and improving the commodity logistics system to address stockouts. 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DATA ANALYSIS Table A–1.1: Characteristics of the 41 facilities visited Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of facilit ies 19 9 7 6 41 Region (B101)* Northern Region 4 (21.1%) 3 (33.3%) 2 (28.6%) 4 (66.7%) 13 (31.7%) Central Region 8 (42.1%) 2 (22.2%) 2 (28.6%) 2 (33.3%) 14 (34.1%) Southern Region 7 (36.8%) 4 (44.4%) 3 (42.9%) 0 14 (34.1%) Visible sign with name of the facility within the premises? (A101) Yes 10 (52.6%) 8 (88.9%) 6 (85.97%) 3 (50.0%) 27 65.9%) No 9 (47.4%) 1 (11.1%) 1 (14.3%) 3 (50.0%) 14 (34.2%) Watchman at the facility? (A103, A103a) At the entrance and providing inform ation to patients 2 (10.5%) 7 (77.8%) 3 (42.9%) 0 12 (29.3%) No watchm an at the facility 17 (89.5%) 2 (22.2%) 4 (57.1%) 6 (100.0%) 29 (70.7%) Presence of OPD reception? (A201, A201a) Yes, and staff m anaging the reception 10 (52.6%) 7 (77.8%) 5 (71.4%) 5 (83.3%) 27 (65.9%) Yes, but no one present to assist client 0 1 (11.1%) 1 (14.3%) 0 2 (4.9%) No reception 9 (47.4%) 1 (11.1%) 1 (14.3%) 1 (16.7%) 12 (29.3%) Location of HCT serv ices at facility (A401, A402) Designated HCT clinic or room within OPD 19 (100%) 9 (100%) 7 (100%) 6 (100%) 41 (100%) Location of ART serv ices provided at this facility (A501,A502) Designated ART clinic/room within OPD 19 (100%) 9 (100%) 7 (100.0%) 2 (33.3%) 37 (90.2%) Integrated into other services 0 0 0 4 (66.7%) 4 (9.8%) Location of FP serv ices prov ided at this facility (A601,A602) Designated FP clinic/room within OPD 19 (100%) 9 (100%) 5 (71.4%) 4 (66.7%) 37 (90.2%) Integrated into other services 0 0 0 2 (28.6%) 2 (4.9%) Did not provide FP 0 0 2 (28.6%) 0 2 (4.9%) Presence of pharmacy at this facility (A701, A702) Yes, and open 15 (78.9%) 9 (100.0%) 7 (100.0%) 5 (83.3%) 36 (87.8%) Yes, but not open 1 (5.3%) 0 0 0 1 (2.4%) No 3 (15.8%) 0 0 1 (16.7%) 4 (9.8%) * Numbers in parentheses denote the question number the data were pulled from Table and appendix numbering reflects the ordering used during original data collection and analysis. Integration of Family Planning and HIV Services in Malawi 32 Table A–1.2: Characteristics of the HCT clinic/room, at outpatient department (OPD) Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of facilities 19 9 7 6 41 Is there an adequate waiting area for patients/clients at the HCT clinic/room? (A403)* Yes 17 (89.5%) 8 (88.9%) 5 (71.4%) 2 (33.3%) 32 (78.0%) No 2 (10.5%) 1 (11.1%) 2 (28.6%) 4 (66.7%) 9 (22.0%) Among the 32 waiting areas observed, number of appropriate waiting areas for patients in the HCT clinic/room (A403a,A403b) Yes, clean with adequate seating 14 (82.4%) 6 (75.0%) 5 (100.0%) 2 (100.0%) 27 (84.4%) Yes, but not clean or adequate 3 (17.7%) 2 (25.0%) 0 0 5 (15.6%) Observ ed HCT provider’s room for seeing patients (A404) Observed 19 (100.0%) 9 (100.0%) 7 (100.0%) 4 (66.7%) 39 (95.1%) None observed 0 0 0 2 (33.3%) 2 (4.9%) Among the 39 HCT prov ider rooms observ ed, setup of the prov ider’s room for seeing patients¥ (A404) Respective seating for provider and patient 1 (6.3%) 0 0 0 1 (2.6%) Well-lit room 1 (6.25%) 0 0 0 1 (2.6%) Auditory and visual privacy 14 (87.5%) 9 (100.0%) 7 (100.0%) 6 (100%) 36 (92.3%) Number of prov iders working at the HCT clinic/room (A405) 0 1 (5.3%) 0 0 0 1 (2.4%) 1 13 (68.4%) 5 (55.6%) 3 (42.9%) 2 (33.3%) 23 (56.1%) 2 4 (21.1%) 1 (11.1%) 1 (14.3%) 2 (33.3%) 8 (19.5%) ≥3 1 (5.3%) 3 (33.3%) 3 (42.9%) 2 (33.3%) 9 (22.0%) Were FP commodities av ailable at HCT clinic/ room? (A407) Yes 16 (84.2%) 8 (88.9%) 6 (85.7%) 5 (83.3%) 35 (85.4%) No 3 (15.8%) 1 (11.1%) 1 (14.3%) 1 (16.7%) 6 (14.6%) Among the 35 HCT clinics/rooms prov iding FP commodities, modern FP commodities and supplies av ailable at the HCT clinic ¥ (A407) Pills 1 (6.25%) 1 (12.5%) 2 (33.3%) 0 4 (11.4%) Male condoms 15 (93.8%) 7 (87.5%) 5 (83.3%) 5 (100.0%) 32 (91.4%) Female condoms 8 (50.0%) 4 (50.0%) 6 (100.0%) 3 (50.0%) 21 (60.0%) Injectables 1 (6.25%) 0 3 (50.0%) 0 4 (11.4%) IUDs 0 0 0 0 0 Implants 0 0 1 0 1 (2.9%) Female sterilization 0 0 0 0 0 Male sterilization 0 0 0 0 0 Emergency contraception (EC) 0 0 0 0 0 Among the 35 HCT clinics/rooms prov iding FP commodities, method of capturing FP data at the HCT clinic (A408) Ext ra columns added in the HCT register 12 (34.3%) 6 (17.2%) 3 (8.6%) 2 (5.7%) 23 (65.7%) Separate FP register maintained 1 (6.3%) 0 1 (16.7%) 1 (20.0%) 3 (8.6%) No not ification made in register 3 (18.8%) 1 (12.5%) 2 (33.3%) 1 (20.0%) 7 (20.0%) Could not check register 0 1 (12.5%) 0 1 (20.0%) 2 (5.7%) Are IEC messages about HIV seen at the HCT clinic/room?1 (A409) Yes 9 (47.4%) 5 (55.6%) 6 (85.7%) 3 (50.0%) 23 (56.1%) No 10 (52.6%) 4 (44.4%) 1 (14.3%) 3 (50.0%) 18 (43.9%) Are IEC messages about FP seen at the HCT clinic/room?2 (A410) Yes 3 (15.8%) 2 (22.2%) 2 (28.6%) 2 (33.3%) 9 (22.0%) No 16 (84.2%) 7 (77.8%) 5 (71.4%) 4 (67.7%) 32 (78.0%) * Numbers in parentheses denote the question number the data were pulled from ¥categories are NOT mutually exclusive 1 IEC messages about HIV includes: HIV prevention, role of FP in HIV prevention, ART adherence, importance of testing, availability of HIV services, signs of OIs, HIV-related nutrition 2IEC messages about FP includes: FP methods, benefits of FP for PLHIV, importance of using FP methods, availability of FP methods, where to get FP methods Annex A. Data Analysis 33 Table A–1.3: Characteristics of the ART clinic/room, at outpatient department (OPD) Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of facilities* 19 9 7 6 41 Is there adequate waiting area for patients/clients at the ART clinic/room? (A503)** Yes 14 (73.7%) 9 (100.0%) 5 (71.4% 4 (66.7%) 32 (78.0%) No 5 (26.3%) 0 2 (28.6%) 2 (33.3%) 9 (22.0%) Of the 32 clinics with adequate waiting area, number with appropriate waiting area for patients in the ART clinic/room¥,(A503a,A503b) Yes, clean with adequate seating 14 (100.0%) 7 (77.8%) 4 (80.0%) 4 (100.0%) 29 (90.6%) Yes, but not clean or adequate 0 2 (22.2%) 1 (20.0%) 0 3 (9.4%) Setup of the prov ider’s room for seeing patients¥ (A504) Respective seating for provider and patient Well-lit room Auditory and visual privacy 1 (5.6%) 2 (11.1%) 15 (83.3%) 0 1 (11.1%) 8 (88.9%) 0 6 (15.0%) 33 (82.5%) 0 0 6 (100.0%) 1 (2.4%) 6 (14.6%) 33 (80.5%) Number of prov iders working at the ART clinic/room (A505) 1 2 ≥3 8 (42.1%) 6 (31.6%) 5 (26.3%) 2 (22.2%) 1 (11.1%) 6 (66.7%) 1 (14.3%) 3 (42.9%) 3 (42.9%) 2 (33.3%) 1 (16.7%) 3 (50.0%) 13 (31.7%) 11 (26.8%) 17 (41.5%) Were FP commodities av ailable at ART clinic/room? (A507) Yes No 16 (84.2%) 3 (15.8%) 8 (88.9%) 1 (11.1%) 6 (85.7%) 1 (14.2%) 5 (83.3%) 1 (16.7%) 35 (85.4%) 6 (14.6%) Among the 35 facilities where FP commodities were av ailable, the type of FP commodities and supplies av ailable at the ART clinic/room¥ (A507) Pills 4 (25.0%) 1 (12.5%) 0 3 (60.0%) 8 (22.9%) Male condoms 16 (100.0%) 7 (87.5%) 6 (100.0%) 5 (100.0%) 34 (97.1%) Female condoms 8 (50.0%) 6 (75.0%) 3 (50.0%) 3 (60.0%) 20 (57.1%) Injectables 4 (25.0%) 1 (12.5%) 2 (33.3%) 4 (80.0%) 11 (31.4%) IUDs 1 (6.3%) 0 1 (16.7%) 0 2 (5.7%) Implants 2 (12.5%) 0 0 3 (60.0%) 5 (14.3%) Female sterilization 0 0 0 0 0 Male sterilization 0 0 0 0 0 EC 1 (6.3%) 0 0 3 (60.0%) 4 (11.4%) Method of capturing FP data at the ART clinic/room (A508) Ext ra columns added in the ART register 2 (12.5%) 2 (25.0%) 1 (16.7%) 1 (20.0%) 6 (17.1%) Separate FP register maintained 5 (31.3%) 2 (25.0%) 0 1 (20.0%) 8 (22.9%) No not ification made in register 3 (18.8%) 1 (12.5%) 0 0 4 (11.4%) Could not check register 6 (33.3%) 3 (37.5%) 5 (83.3%) 3 (60.0%) 17 (48.6%) Are IEC messages about HIV seen at the ART clinic/room?1 (A509) Yes 9 (47.4%) 5 (55.6%) 4 (57.1%) 2 (33.3%) 20 (48.8%) No 10 (52.6%) 4 (44.4%) 3 (42.9%) 4 (66.7%) 21 (51.2%) Are IEC messages about FP seen at the ART clinic/room?2 (A510) Yes 7 (36.8%) 3 (33.3%) 1 (14.3%) 4 (66.7%) 15 (36.6%) No 12 (63.2%) 6 (66.7%) 6 (85.7%) 2 (33.3%) 26 (63.4%) * Numbers in parentheses denote the question number the data were pulled from ** The ART clinics/rooms observed included stand-alone clinics, as well as rooms within a larger OPD where providers were giving ART services ¥ categories are NOT mutually exclusive 1 IEC messages about HIV includes: HIV prevention, role of FP in HIV prevention, ART adherence, Importance of testing, availability of HIV services, signs of OIs, HIV-related nutrition 2 FP-related messages includes: FP Methods, benefits of FP for PLHIV, importance of using FP methods, availability of FP methods, where to get FP methods Integration of Family Planning and HIV Services in Malawi 34 Table A–1.4: Characteristics of the FP clinic/room, at outpatient department (OPD) Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of FP clinics and FP rooms observ ed* 15 9 3 6 33 Is there appropriate waiting area for patients in the FP clinic? (A603a,A603b) ** Yes, clean with adequate seating 12 (80.0%) 6 (66.7%) 3 (100.0%) 5 (83.3%) 28 (84.8%) Yes, not clean but adequate seat ing 3 (20.0%) 3 (33.3%) 0 1 (16.7%) 5 (15.2%) Was FP prov ider’s room for seeing patients observ ed? (A604) Observed 15 (100.0%) 8 (88.9%) 3 (100.0%) 6 (100.0%) 32 (97.0%) None observed 0 1 (11.1%) 0 0 1 (3.0%) Of the 32 prov ider rooms observ ed, setup of the prov ider’s room for seeing patients† (A604) Respective seating for provider and pat ient 11 (73.3%) 6 (75.0%) 3 (100.0%) 2 (33.3%) 23 (71.9%) Well-lit room 11 (73.3%) 6 (75.0%) 3 (100.0%) 1 (16.7%) 21 (65.6%) Auditory and visual privacy 10 (66.7%) 4 (50.0%) 3 (100.0%) 2 (33.3%) 19 (59.4%) Number of prov iders working at the FP clinic (A605) 0 0 0 1 (33.3%) 1 (16.7%) 2 (6.1%) 1 2 ≥3 9 (60.0%) 4 (26.7%) 2 (13.3%) 2 (22.2%) 4 (44.4%) 2 (22.2%) 2 (66.6%) 0 1 (33.3%) 1 (16.7%) 2 (33.3%) 2 (33.3%) 14 (42.4%) 10 (30.3%) 7 (21.2%) Modern FP commodities and supplies av ailable at the FP clinic† (A607) Pills 10 (66.7%) 6 (66.7%) 3 (100.0%) 3 (50.0%) 22 (66.7%) Male condoms 11 (73.3%) 6 (66.7%) 3 (100.0%) 3 (50.0%) 23 (69.7%) Female condoms 9 (60.0%) 6 (66.7%) 3 (100.0%) 2 (33.3%) 20 (60.6%) Injectables 11 (73.3%) 6 (66.7%) 3 (100.0%) 3 (5.0%) 23 (69.7%) IUD 3 (20.0%) 4 (44.4%) 1 (33.3%) 0 8 (24.2%) Implants 9 (60.0%) 5 (55.6%) 2 (66.7%) 2 (33.3%) 18 (54.5%) Female sterilization 1 (6.7%) 2 (22.2%) 0 0 3 (9.1%) Male sterilization 0 1 (11.1%) 0 0 1 (3.0%) Emergency contraception 5 (33.3%) 4 (44.4%) 1 (33.3%) 2 (33.3%) 12 (36.4%) Are HIV serv ices prov ided at the FP clinic? (A608) Yes 11 (73.3%) 7 (77.8%) 2 (66.7%) 5 (83.3%) 25 (75.8%) No 4 (26.7%) 2 (22.2%) 1 (33.3%) 1 (16.7%) 8 (24.2%) Of the 25 facilities with HIV serv ices prov ided at the FP clinic, types of HIV serv ices prov ided† (A608a) HCT 2 (18.2%) 3 (42.9%) 1 (50.0%) 2 (40.0%) 8 (32.0%) PMTCT 5 (45.5%) 3 (42.9%) 0 2 (40.0%) 10 (40.0%) Other HIV services 9 (81.2%) 5 (71.4%) 1 (50.0%) 3 (60.0%) 18 (72.0%) Were IEC messages on HIV seen at the FP clinic?2 Yes 7 (46.7%) 4 (44.4%) 1 (33.3%) 2 (33.3%) 14 (42.4%) No 8 (53.3%) 5 (55.6%) 2 (66.7%) 4 (66.7%) 19 (57.6%) Were IEC messages on FP seen at the FP clinic2 Yes 9 (56.3%) 6 (66.7%) 3 (100.0%) 2 (33.3%) 20 (60.6%) No 7 (43.8%) 3 (33.3%) 0 4 (66.7%) 13 (39.4%) *Eight facilities had no FP clinic on the day of observation. Of those facilities, two do not have a FP clinic at all and the other six have FP clinics but they were not operating on the day of observation. Hence, only 33 FP clinics/rooms were observed. **Numbers in parentheses denote the question number the data were pulled from † Categories are NOT mutually exclusive 1 IEC messages on HIV includes IV: HIV prevention, role of FP in HIV prevention, ART adherence, importance of testing, availability of HIV services, signs of OIs, HIV-related nutrition 2 IEC messages on includes: FP Methods, benefits of FP for PLHIV, importance of using FP methods, availability of FP methods, where to get FP methods Annex A. Data Analysis 35 Table A–2: Demographics of facility-in-charge within selected facilities, by facility type Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of facility in-charges 19 9 7 6 41 Age (B201)* 20–30 9 (47.4%) 3 (33.3%) 2 (28.6%) 4 (66.7%) 18 (43.9%) 31–40 5 (26.3%) 2 (22.2%) 0 0 7 (17.1%) 41–50 2 (10.5%) 1 (11.1%) 2 (28.6%) 2 (33.3%) 7 (17.1%) ≥51 Missing data/no response 2 (10.5%) 1 (5.3%) 3 (33.3%) 3 (42.9%) 0 8 (19.5%) Gender (B202) Male 14 (73.7%) 6 (66.7%) 4 (57.1%) 3 (50.0%) 27 (65.8%) Female 5 (26.3%) 3 (33.3%) 3 (42.9%) 3 (50.0%) 14 (34.2%) Current occupation (B203) Medical Doctor 1 (5.3%) 4 (44.4%) 2 (28.6%) 0 7 (17.1%) Registered Nurse/Midwife 1 (5.3%) 3 (33.3%) 1 (14.3%) 0 5 (12.2%) Clinical Officer 3 (15.8%) 2 (22.2%) 2 (28.6%) 1 (16.7%) 8 (19.5%) Paramedical worker1 14 (73.7%) 0 2 (28.6%) 5 (83.3%) 21 (51.2%) How long hav e you worked since you last graduated? (B204) ≤1yr 2 (10.5%) 0 1 (14.3%) 1 (16.7%) 4 (9.8%) 2-5yrs 8 (42.1%) 5 (55.6%) 2 (28.6%) 2 (33.3%) 17 (41.5%) 6-10yrs 4 (21.1%) 1 (11.1%) 1 (14.3%) 1 (16.7%) 7 (17.1%) ≥11yrs 5 (26.3%) 3 (33.3%) 3 (42.9%) 2 (33.3%) 13 (31.7%) Have you receiv ed any training in FP serv ices? (B301) Yes 18 (94.7%) 6 (66.7%) 4 (57.1%) 5 (83.3%) 33 (80.5%) No 1 (5.3%) 3 (33.3%) 3 (42.9%) 1 (16.7%) 8 (19.5%) Of the 33 prov iders who received training in FP serv ices, the type of training they receiv ed in prov iding FP serv ices¥ (B301) Pre-service FP 14 (77.8%) 3 (50.0%) 2 (50.0%) 3 (60.0%) 22 (66.7%) Short -acting methods2 7 (38.9%) 2 (33.3%) 2 (50.0%) 3 (60.0%) 14 (42.4%) Implant2 13 (72.2%) 1 (16.7%) 1 (25.0%) 3 (60.0%) 18 (54.5%) IUD 10 (55.6%) 2 (33.3%) 1 (25.0%) 3 (60.0%) 16 (48.5%) Sterilization (male/female) 1 (5.6%) 1 (16.7%) 0 2 (40.0%) 4 (12.1%) Have you receiv ed any training in providing HIV serv ices (B302) Yes 19 (100.0%) 7 (77.8%) 6 (85.7%) 6 (100.0%) 38 (92.7%) No 0 2 (22.2%) 1 (14.3%) 0 3 (7.3%) Of the 38 prov iders who have received HIV training, the type of training they receiv ed in prov iding HIV serv ices¥ (B302) HCT 10 (52.6%) 2 (28.6%) 2 (33.3%) 2 (33.3%) 16 (42.1%) PMTCT 15 (78.9%) 5 (71.4%) 3 (50.0%) 4 (66.7%) 27 (71.1%) Other HIV services3 17 (89.5%) 7 (100.0%) 6 (100.0%) 6 (100.0%) 36 (94.7%) Have you receiv ed training in providing FP/SRH and HIV integration services (B303) Yes 9 (47.4%) 2 (22.2%) 1 (14.3%) 4 (66.7%) 16 (39.0%) No 10 (52.6%) 7 (77.8%) 6 (85.7%) 2 (33.3%) 25 (61.0%) Of the 16 prov iders who received FP/SRH and HIV training, entity that provided the training¥ (B303, B303b) Medical/nursing t raining 0 0 0 2 (50.0%) 2 (12.5%) MOH 3 (33.3%) 0 0 1 (25.0%) 4 (25.0%) Donors/implementing partners4 6 (66.7%) 1 (50.0%) 1 (100.0%) 2 (50.0%) 10 (62.5%) *Numbers in parentheses denote the question number the data were pulled from 1 Paramedical workers include: Nurse midwife, technician, medical assistant, auxiliary nurse, patient attendant, HIV counselor 2 Short-acting methods include: pills, female condoms, EC, Implant include: Jadelle, Implanon, norplant 3 Other HIV services includes: HIV monitoring, ART, condom provision, management of OIs, HIV-related nutrition support 4Donors/implementing partners includes: UNFPA, SSDI-Jhpiego, BLM, Outside Malawi ¥Categories are NOT mutually exclusive Integration of Family Planning and HIV Services in Malawi 36 Table A–2.1: Integration of FP services into ART services, by facility type, based on interviews with in-charge A. Total number n=41 Integration Model Family Planning Services Reproductive decision counseling Male condoms Injectables Pills IUD Implants BTL Vasectomy Other short- acting (EC, female condoms) Same clinic, same day* 28 (68.3%) 40 (97.6%) 17 (41.5%) 15 (36.6%) 3 (7.3%) 8 (19.5%) 0 0 24 (58.5%) Same facility, different room, same day 17 (41.5%) 7 (17.1%) 23 (56.1%) 26 (63.4%) 16 (39.0%) 22 (53.7%) 7 (17.1%) 4 (9.8%) 15 (36.6%) Same facility, different day 1 (2.4%) 0 4 (9.8%) 4 (9.8%) 10 (24.4%) 11 (26.8%) 13 (31.7%) 11 (26.8%) 2 (4.9%) Referred out to another facility/ pharmacy† 2 (4.9%) 1 (2.4%) 2 (4.9%) 2 (4.9%) 13 (31.7%) 5 (12.2%) 17 (41.5%) 17 (41.5%) 1 (2.4%) BLM outreach 0 0 0 0 11 (26.8%) 4 (9.8%) 15 (36.6%) 16 (39.0%) 0 None 0 0 0 0 0 0 1 (2.4%) 3 (7.3%) 1 (2.4%) Community- based HSAs 1 (2.4%) 1 (2.4%) 1 (2.4%) 1 (2.4%) 0 0 0 0 1 (2.4%) *same clinic same day includes two categories of integration: same clinic, same provider and same clinic, different provider †referred out to another facility/pharmacy includes three categories of integration: another facility, same day; another facility, different day; and refer to pharmacy B. Health centres n=19 Integration Model Family Planning Services Reproductive decision counseling Male condoms Injectables Pills IUD Implants BTL Vasectomy Other short- acting (EC, female condoms) Same clinic, same day 15 (78.9%) 19 (100%) 10 (52.6%) 9 (47.4%) 1 (5.3%) 4 (21.1%) 0 0 13 (68.4%) Same facility, different room, same day 6 (31.6%) 2 (10.5%) 8 (42.1%) 10 (52.6%) 3 (15.8%) 8 (42.1%) 0 0 5 (26.3%) Same facility, different day 0 0 2 (10.5%) 2 (10.5%) 6 (31.6%) 8 (42.1%) 5 (26.3%) 5 (26.3%) 0 Referred out to another facility/ pharmacy 0 0 0 0 7 (36.8%) 1 (5.3%) 10 (52.6%) 10 (52.6%) 0 BLM outreach 0 0 0 0 8 (42.1%) 2 (10.5%) 11 (57.9%) 10 (52.6%) 0 None 0 0 0 0 0 0 0 0 0 Annex A. Data Analysis 37 C. Public hospitals n=9 Integration Model Family Planning Services Reproductive decision counseling Male condoms Injectables Pills IUD Implants BTL Vasectomy Other short- acting (EC, female condoms) Same clinic, same day 5 (55.6%) 9 (100.0%) 0 0 0 0 0 0 3 (33.3%) Same facility, different room, same day 4 (44.4%) 2 (22.2%) 8 (88.9%) 8 (88.9%) 8 (88.9%) 8 (88.9%) 5 (55.6%) 3 (33.3%) 5 (55.6%) Same facility, different day 0 0 1 (11.1%) 1 (11.1%) 3 (33.3%) 2 (22.2%) 6 (66.7%) 5 (55.6%) 1 (11.1%) Referred out to another facility/ pharmacy 0 0 0 0 0 0 1 (11.1%) 1 (11.1%) 0 BLM outreach 0 0 0 0 0 0 0 1 (11.1%) 0 None 0 0 0 0 0 0 0 0 0 D. CHAM n=5* Integration Model Family Planning Services Reproductive decision counseling Male condoms Injectables Pills IUD Implants BTL Vasectomy Other short- acting (EC, female condoms) Same clinic, same day 3 (60.0%) 5 (100.0%) 3 (60.0%) 2 (40.0%) 0 1 (20.0%) 0 0 5 (100.0%) Same facility, different room, same day 3 (60.0%) 0 3 (60.0%) 4 (80.0%) 2 (40.0%) 2 (40.0%) 1 (20.0%) 1 (20.0%) 2 (40.0%) Same facility, different day 1 (20.0%) 0 1 (20.0%) 1 (20.0%) 0 0 1 (20.0%) 0 1 (20.0%) Referred out to another facility/ pharmacy 1 (20.0%) 0 1 (20.0%) 1 (20.0%) 4 (80.0%) 3 (60.0%) 4 (80.0%) 4 (80.0%) 0 BLM outreach 0 0 0 0 1 (20.0%) 1 (20.0%) 1 (20.0%) 1 (20.0%) 0 None 0 0 0 0 0 0 0 1 (20.0%) 0 Community- based HSAs 1 (20.0%) 1 (20.0%) 1 (20.0%) 1 (20.0%) 0 0 0 0 1 (20.0%) *There were a total of 7 CHAM clinics, but only 5 provided family planning; 6 provided condoms as HIV services Integration of Family Planning and HIV Services in Malawi 38 E. Integrated facilities n=6 Integration Model Family Planning Services Reproductive decision counseling Male condoms Injectables Pills IUD Implants BTL Vasectomy Other short- acting (EC, female condoms) Same clinic, same day 5 (83.3%) 6 (100.0%) 4 (66.7%) 4 (66.7%) 2 (33.3%) 3 (50.0%) 0 0 3 (50.0%) Same facility, different room, same day 4 (66.7%) 3 (50.0%) 4 (66.7%) 4 (66.7%) 3 (50.0%) 4 (66.7%) 1 (16.7%) 0 3 (50.0%) Same facility, different day 0 0 0 0 1 (16.7%) 1 (16.7%) 1 (16.7%) 1 (16.7%) 0 Referred out to another facility/ pharmacy 1 (16.7%) 1 (16.7%) 1 (16.7%) 1 (16.7%) 2 (33.3%) 1 (16.7%) 2 (33.3%) 2 (33.3%) 1 (16.7%) BLM outreach 0 0 0 0 2 (33.3%) 1 (16.7%) 3 (50.0%) 4 (66.7%) 0 None 0 0 0 0 0 0 1 (16.7%) 2 (33.3%) 1 (16.7%) Annex A. Data Analysis 39 Table A–2.2: Description of health services provided according to facility-in-charge, by facility type Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of facilities 19 9 7 6 41 FP serv ices prov ided at this facility¥ (B402)* RH counseling 19 (100.0%) 9 (100.0%) 5(71.4%) 6 (83.3%) 39 (95.1%) Pills 18 (94.7%) 8 (88.9%) 5 (71.4%) 6 (100.0%) 37 (90.2%) Male condoms 18 (94.7%) 9 (100.0%) 5 (71.4%) 6 (100.0%) 38 (92.7%) Female condoms 18 (94.7%) 9 (100.0%) 5 (71.4%) 5 (83.3%) 37 (90.2%) Injectables 18 (94.7%) 9 (100.0%) 5 (71.4%) 6 (100.0%) 38 (92.7%) IUD 10 (94.7%) 7 (77.8%) 2 (28.6%) 4 (66.7%) 23 (56.1%) Implants 14 (73.7%) 9 (100.0%) 4 (57.1%) 6 (100.0%) 33 (80.5%) Female sterilization 1 (5.2%) 9 (100.0%) 2 (28.6%) 2 (33.3%) 14 (34.1%) Male sterilization 2 (10.5%) 5 (55.6%) 1 (14.3%) 1 (16.7%) 9 (21.9%) Emergency contraception 9 (24.5%) 7 (77.8%) 5 (71.4%) 3 (50.0%) 24 (58.5%) Of the 39 facilities that provide FP, where clients can receiv e FP at this facility¥ (B403) Designated FP clinic 14 (73.7%) 8 (88.9%) 3 (60.0%) 5 (83.3%) 30 (76.9%) ANC/PMTCT clinic 4 (21.1%) 1 (11.1%) 0 3 (50.0%) 8 (20.5%) OPD1 5 (26.3%) 2 (22.2%) 3 (60.0%) 4 (66.7%) 14 (35.9%) IPD1 1 (5.3%) 3 (33.3%) 0 3 (50.0%) 7 (17.9%) HCT clinic 3 (15.8%) 0 0 3 (50.0%) 6 (15.4%) ART clinic 5 (26.3%) 1 (11.1%) 1 (20.0%) 3 (50.0%) 10 (25.6%) Of the 30 facilities that have a designated FP clinic, number of days per week when FP clinic is open (B403aa) Once a week 7 (50.0%) 0 1 (33.3%) 1 (20.0%) 9 (30.0%) 2–4 t imes a week 2 (14.3%) 0 0 0 2 (6.7%) 5 or more t imes a week 5 (35.7%) 8 (100.0%) 2 (66.7%) 4 (80.0%) 19 (63.3%) Of the 39 facilities that provide FP, have FP commodities been stocked out or expired in the last three months (B404) Yes 12 (63.2%) 3 (33.3%) 2 (40.0%) 0 17 (43.6%) No 7 (36.8%) 6 (66.7%) 3 (60.0%) 6 (100.0%) 22 (56.4%) Of the 17 facilities that have experienced stockouts, which methods? (B404) Pills 5 (41.7%) 2 (66.7%) 1 (50.0%) 0 8 (47.1%) Male condoms 5 (41.7%) 2 (66.7%) 1 (50.0%) 0 8 (47.1%) Female condoms 2 (16.7%) 2 (66.7%) 1 (50.0%) 0 5 (29.4%) Injectables 6 (50.0%) 2 (66.7%) 1 (50.0%) 0 8 (47.1%) IUDs 1 (8.3%) 2 (66.7%) 1 (50.0%) 0 3 (17.6%) Implants 3 (25.0%) 2 (66.7%) 0 0 5 (29.4%) Emergency Contraception 0 0 1 (50.0%) 0 1 (5.8%) Location of ART serv ices at this facility¥ (B407) Designated ART clinic 17 (89.5%) 8 (88.9%) 7 (100.0%) 5 (83.3%) 37 (90.2%) ANC/PMTCT clinic 2 (10.5%) 3 (33.3%) 1 (14.3%) 6 (100.0%) 12 (29.3%) OPD1 2 (10.5%) 3 (33.3%) 0 4 (66.7%) 9 (21.9%) IPD2 3 (15.8%) 1 (11.1%) 1 (14.3%) 4 (66.7%) 9 (21.9%) HCT clinic 0 1 (11.1%) 0 2 (33.3%) 3 (7.3%) FP clinic 1 (5.3%) 0 0 2 (33.3%) 3 (7.3%) Number of days per week when ART clinic is open (B407a) Once a week 11 (57.9%) 1 (11.1%) 2 (28.6%) 1 (16.7%) 15 (36.6%) 2–4 t imes a week 2 (10.5%) 1 (11.1%) 1 (14.3%) 0 4 (9.8%) 5 or more t imes a week 5 (26.3%) 6 (66.7%) 4 (57.1%) 5 (83.3%) 20 (48.8%) None provided at this facility 1 (5.3%) 1 (11.1%) 0 0 2 (4.9%) Location of PMTCT serv ices at this facility¥ (B408) PMTCT/ ANC Clinic 15 (78.9%) 8 (88.8%) 6 (85.7%) 5 (83.3%) 34 (82.9%) Other location3 18 (94.7%) 8 (88.9%) 7 (100.0%) 5 (83.3%) 38 (92.7%) Number of days per week when PMTCT clinic is open (B408a) Once a week 0 0 1 (14.3%) 0 1 (2.4%) 2–4 t imes a week 7 (36.8%) 0 3 (42.9%) 1 (16.7%) 11 (26.8%) 5 or more t imes a week 12 (63.2%) 8 (100.0%) 3 (42.9%) 5 (83.3%) 28 (68.3%) None provided at this facility 0 1 (11.1%) 0 0 1 (2.4%) Integration of Family Planning and HIV Services in Malawi 40 Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) HIV commodities that have stocked out or expired in the past 3 months¥ (B409) HCT kit s 6 (31.6%) 4 (44.4%) 2 (28.6%) 2 (33.3%) 14 (34.1%) ARVs 7 (36.8%) 3 (33.3%) 0 0 10 (24.4%) Opportunistic infections drugs 3 (15.8%) 1 (11.1%) 1 (14.3%) 1 (16.7%) 6 (14.6%) Injectables 1 (5.3%) 0 0 0 1 (2.4%) Condoms 2 (10.5%) 1 (11.1%) 1 (14.3%) 0 4 (9.8%) Other commodities4 2 (10.5%) 0 1 (14.3%) 0 3 (7.3%) Routine HIV serv ices provided by community health workers to HIV patients in their home/community ¥ (B410) HCT 1 (5.3%) 1 (11.1%) 2 (28.6%) 2 (33.3%) 6 (14.6%) PMTCT 0 1 (11.1%) 1 (14.3%) 0 2 (4.9%) ART 2 (10.5%) 0 2 (28.6%) 0 4 (9.8%) Other HIV services5 6 (31.6%) 3 (33.3%) 5 (71.4%) 5 (83.3%) 19 (46.3%) Are FP serv ices prov ided to HIV patients within their homes(B410b) Yes 6 (31.6%) 3 (33.3%) 3 (42.9%) 4 (66.7%) 16 (39.0%) No 13 (68.4%) 6 (66.7%) 4 (57.1%) 2 (33.3%) 25 (60.9%) Of the 16 facilities that support community distribution of FP serv ices to HIV patients, routine FP serv ices prov ided by community health workers to HIV patients in their home/community ¥ (B410b) RH counseling 6 (100.0%) 3 (100.0%) 3 (100.0%) 4 (100.0%) 16 (100.0%) Male condoms 6 (100.0%) 3 (100.0%) 3 (100.0%) 4 (100.0%) 16 (100.0%) Injectables 2 (33.3%) 0 0 2 (50.0%) 4 (25.0%) Pills 3 (50.0%) 1 (33.3%) 2 (66.7%) 0 6 (37.5%) Female condoms 6 (100.0%) 3 (100.0%) 3 (100.0%) 3 (75.0%) 15 (93.8%) Emergency contraception 0 0 0 0 0 *Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive 1OPD includes: postnatal, Under-five clinic 2 IPD includes: labor and delivery, operating room (theater/surgery) 3Other Locations includes: FP clinic, OPD, HCT, ART, IPD 4Other commodities includes: PMTCT 5Other HIV services includes: HIV monitoring, condom provision, management of OIs, HIV-related nutrition support Annex A. Data Analysis 41 Table A–3: Demographics of health service provider within selected facilities, by facility type Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of prov iders 54 (44.3%) 32 (26.2%) 21 (17.2%) 15 (12.3%) 122 (100.0%) Age (C101)* 20–30 17 (31.5%) 7 (21.9%) 5 (23.8%) 7 (46.7%) 36 (29.5%) 31–40 19 (35.2%) 13 (40.6%) 9 (42.9%) 5 (33.3%) 46 (37.7%) 41–50 11 (20.4%) 7 (21.9%) 2 (9.5%) 1 (6.7%) 21 (17.2%) ≥51 7 (12.9%) 5 (15.6%) 5 (23.8%) 2 (13.3%) 19 (15.6%) Gender (C102) Male 30 (55.6%) 11 (34.4%) 9 (42.9%) 5 (33.3%) 55 (45.1%) Female 24 (44.4%) 21 (65.6%) 12 (57.1%) 10 (66.7%) 67 (54.9%) Current Occupation (C103) Registered Nurse/Midwife 4 (7.6%) 5 (15.6%) 2 (9.5%) 3 (20.0%) 14 (11.5%) Clinical Officer 4 (7.6%) 7 (21.9%) 3 (14.3%) 0 14 (11.5%) HSA 21 (39.6%) 1 (3.1%) 2 (9.5%) 2 (13.3%) 26 (21.3%) Paramedical worker1 24 (45.3%) 19 (59.4%) 14 (66.7%) 10 (66.7%) 67 (54.9%) Length of time working at this facility (C103a) ≤1yr 9 (16.7%) 3 (9.4%) 1 (4.8%) 4 (26.7%) 17 (13.9%) 2–5yrs 20 (37.0%) 12 (37.5%) 7 (33.3%) 2 (13.3%) 41 (33.6%) 6–10yrs 15 (27.8%) 10 (31.3%) 5 (23.8%) 4 (26.7%) 34 (27.8%) ≥11yrs 10 (18.5%) 7 (21.9%) 8 (38.1%) 5 (33.3%) 30 (24.6%) How long hav e you worked since you last graduated (C104) ≤1yr 2 (3.7%) 1 (3.1%) 0 4 (26.7%) 7 (5.7%) 2–5yrs 16 (29.6%) 4 (12.5%) 6 (28.6%) 3 (20.0%) 29 (23.8%) 6–10yrs 17 (31.5%) 12 (37.5%) 3 (14.3%) 4 (26.7%) 36 (29.5%) ≥11yrs 19 (35.2%) 15 (46.9%) 12 (57.1%) 4 (26.7%) 50 (40.9%) Have you receiv ed any training in prov iding FP serv ices(C201) Yes 41 (75.9%) 28 (87.5%) 15 (71.4%) 12 (80.0%) 96 (78.7%) No 13 (24.1%) 4 (12.5%) 6 (28.6%) 3 (20.0%) 26 (21.3%) Of the 96 prov iders who have receiv ed FP training, the training they receiv ed in providing FP serv ices¥ (C201) Pre-service FP 22 (53.7%) 25 (89.3%) 12 (80.0%) 6 (50.0%) 65 (67.7%) Injectables 4 (9.8%) 0 0 2 (16.7%) 6 (6.3%) Short -acting methods2 23 (56.1%) 16 (57.1%) 5 (33.3%) 7 (58.3%) 51 (53.1%) Implant 25 (60.9%) 15 (53.6%) 4 (26.7%) 7 (58.3%) 51 (53.1%) IUD 15 (36.6%) 14 (50%) 3 (23%) 4 (33.3%) 36 (37.5%) BTL 1 (2.4%) 7 (25%) 2 (13.3%) 1 (8.3%) 11 (11.5%) Vasectomy 0 4 (14.3%) 2 (13.3%) 1 (8.3%) 7 (7.3%) Have you receiv ed any training in prov iding HIV serv ices? (C202) Yes 49 (90.7%) 31 (96.8%) 20 (95.2%) 14 (93.3%) 114 (93.4%) No 5 (9.3%) 1 (3.1%) 1 (4.8%) 1 (6.7%) 8 (6.6%) Of the 114 prov iders who received HIV training, the training receiv ed in prov iding HIV serv ices¥ (C202) HCT 28 (57.1%) 14 (45.2%) 7 (35.0%) 5 (35.7%) 54 (47.4%) PMTCT 32 (65.3%) 24 (77.2%) 12 (60.0%) 11 (78.6%) 79 (69.3%) Other HIV services3 43 (87.8%) 30 (96.8%) 20 (100.0%) 12 (85.7%) 105 (92.1%) Receiv ed training in FP/SRH and HIV integration (C203) Yes 12 (22.2%) 8 (25.0%) 4 (19.1%) 5 (33.3%) 29 (23.8%) No 42 (77.8%) 24 (75.0%) 15 (71.4%) 10 (66.7%) 91 (74.6%) Not sure 0 0 2 (9.5%) 0 2 (1.6%) *Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive 1Paramedical workers include: Nurse midwife technician, medical assistant, auxiliary nurse, patient attendant, HIV counselor 2Short-acting methods include: pills, female condoms, EC, Implant include: Jadelle, Implanon, Norplant; Long-acting methods include: IUD, Implants, Female and Male sterilization 3 Other HIV services includes: HIV monitoring, ART, condom provision, management of OIs, HIV-related nutrition support Integration of Family Planning and HIV Services in Malawi 42 Table A–3.1: Description of FP-HCT integration services according to the health service provider within selected facilities, by facility type Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of prov iders 54 (44.3%) 32 (26.2%) 21 (17.2%) 15 (12.3%) 122 (100.0%) Serv ices that you provide weekly at this facility¥(C302)* ANC 28 (51.9%) 12 (37.5%) 11 (52.4%) 12 (80.0%) 63 (51.6%) FP clinic 35 (64.8%) 18 (56.3%) 10 (47.6%) 13 (86.7%) 76 (62.3%) HIV services 43 (79.6%) 27 (84.4%) 18 (85.7%) 10 (66.7%) 98 (80.3%) Have ART serv ices been re-organized to accommodate FP serv ices? (C402) Yes 43 (79.6%) 26 (81.3%) 17 (80.9%) 15 (100.0%) 101 (82.4%) No 11 (20.4%) 6 (18.8%) 4 (19.0%) 0 21 (17.2%) How ART serv ices have been re-organized to accommodate provision of FP serv ices?¥ (C402) More space has been created 8 (18.6%) 4 (15.4%) 3 (17.7%) 4 (26.7%) 19 (18.8%) ART on-site protocols have been revised to accommodate FP services 12 (27.9%) 17 (65.4%) 5 (29.4%) 8 (53.3%) 42 (41.6%) ART providers t rained in different methods of FP 21 (48.8%) 11 (42.3%) 4 (23.5%) 12 (80.0%) 48 (47.5%) Informal referral agreements within the facility created 26 (60.5%) 14 (53.8%) 6 (35.3%) 5 (33.3%) 51 (50.5%) Facility referral agreements across facilit ies developed 14 (32.6%) 10 (38.5%) 5 (29.4%) 2 (13.3%) 31 (30.7%) ART client registers revised to accommodate FP services 4 (9.3%) 4 (15.4%) 1 (5.9%) 2 (13.3%) 11 (10.9%) Operating t ime for ART services adjusted 7 (16.3%) 2 (7.7%) 2 (11.8%) 4 (26.7%) 15 (14.9%) ART/FP provided on the same day 3 (6.9%) 3 (11.5%) 1 (5.9%) 0 7 (6.9%) Do you hav e time/opportunity to counsel ART clients on FP methods? Yes 51 (94.4%) 29 (90.6%) 20 (95.5%) 14 (93.3%) 114 (93.4%) No 2 (3.7%) 2 (6.3%) 1 (4.8%) 1 (6.7%) 6 (4.9%) Not sure 1 (1.9%) 1 (3.1%) 0 0 2 (1.6%) Of the 114 prov iders who counseled ART clients on FP, what FP methods do you counsel ART clients on?¥ (C405a) Pills 44 (86.3%) 21 (72.4%) 18 (90.0%) 12 (85.7%) 95 (83.3%) Male condoms 51 (100.0%) 26 (89.7%) 20 (100.0%) 14 (100.0%) 111 (97.4%) Female condoms 45 (88.2%) 25 (86.2%) 19 (95.0%) 13 (92.9%) 102 (89.5%) Injectables 47 (92.2%) 26 (89.7%) 20 (100.0%) 14 (100.0%) 107 (93.9%) IUD 28 (54.9%) 18 (62.1%) 12 (60.0%) 5 (35.7%) 63 (55.3%) Implants 43 (84.3%) 19 (65.5%) 16 (80.0%) 10 (71.4%) 88 (77.2%) Female sterilization 34 (66.7%) 20 (69.0%) 11 (55.0%) 7 (50.0%) 72 (63.2%) Male sterilization 25 (49.0%) 13 (44.8%) 7 (35.0%) 5 (35.7%) 50 (43.9%) Emergency contraception 19 (37.3%) 17 (58.6%) 10 (50.0%) 5 (35.7%) 51 (44.7%) *Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive Annex A. Data Analysis 43 Table A–3.2: Description of FP-HCT integration services according to the health service provider within selected facilities, by facility type Integration Models Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of prov iders who report a reorganization in FP to accommodate HIV serv ices 44 26 14 13 97 How FP serv ices have been reorganized to accommodate clients with HIV¥ (C410)* More space has been created 6 (13.6%) 6 (23.1%) 3 (21.4%) 4 (30.8%) 19 (19.6%) FP protocols have been revised to accommodate HIV services 15 (34.1%) 13 (50.0%) 1 (7.1%) 8 (61.5%) 37 (38.1%) FP providers trained in different components of HIV 23 (52.3%) 14 (53.8%) 4 (28.6%) 9 (69.2%) 50 (51.5%) Within facility referral agreements created 28 (63.6%) 15 (57.7%) 5 (35.7%) 8 (61.5%) 56 (57.7%) Inter-facility referral agreements developed 18 (40.9%) 7 (26.9%) 4 (28.6%) 1 (7.7%) 30 (30.9%) FP client registers revised to accommodate HIV services 11 (25.0%) 5 (19.2%) 1 (7.1%) 2 (15.4%) 19 (19.6%) Operating t ime for FP services adjusted 3 (6.8%) 2 (7.7%) 2 (14.3%) 2 (15.4%) 9 (9.3%) ¥Categories are NOT mutually exclusive *Numbers in parentheses denote the question number the data were pulled from Integration of Family Planning and HIV Services in Malawi 44 Table A–3.3: Details on referral services according to the health service provider within selected facilities, by facility type Referral Details Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Are clients referred out for serv ices? (C413)* Yes 48 (88.9%) 15 (46.9%) 16 (76.2%) 12 (80.0%) 91 (74.6%) No 6 (11.1%) 17 (53.1%) 5 (23.8%) 3 (20.0%) 31 (25.4%) Of the 91 prov iders who refer clients out for serv ices, what prior knowledge do you have of facilities to which you are referring clients for HIV serv ices?¥ (C413a) Services provided 33 (68.8%) 6 (40.0%) 11 (68.9%) 7 (58.3%) 57 (62.6%) Weekdays on which services are provided 31 (64.6%) 5 (33.3) 7 (43.8%) 6 (50.0%) 49 (53.8%) Times when services are provided 20 (41.7%) 3 (20.0%) 5 (31.2%) 3 (25.0%) 31 (34.1%) Transport costs to reach the referral site 13 (27.1%) 4 (26.7%) 3 (18.8%) 4 (33.3%) 24 (26.4%) No prior knowledge 5 (10.4%) 7 (46.7%) 1 (6.3%) 1 (8.3%) 14 (15.4%) Of the 91 prov iders who refer clients out for serv ices, what prior knowledge do they have of facilities to which you are referring clients for FP serv ices ?¥ (C413b) Services provided 32 (66.7%) 10 (66.7%) 12 (75.0%) 9 (75.0%) 63 (69.2%) Weekdays on which services are provided 34 (70.8%) 11 (73.3%) 6 (37.5%) 7 (58.3%) 58 (63.7%) Times when services are provided 25 (52.1%) 5 (33.3%) 5 (31.3%) 5 (41.7%) 40 (44.0%) Transport costs to reach the referral site 14 (29.2%) 3 (20.0%) 5 (31.3%) 4 (33.3%) 26 (28.6%) No prior knowledge 5 (10.4%) 5 (33.3%) 1 (6.3%) 2 (16.7%) 13 (14.3%) Of the 91 prov iders who refer clients out for serv ices, do they have a follow-up mechanism to confirm if clients acted on referrals? (C414) Yes 39 (81.3%) 15 (100.0%) 14 (87.5%) 9 (75.0%) 77 (84.6%) No/Not sure 9 (18.7%) 0 (0.0%) 2 (12.5%) 3 (25.0%) 14 (15.4%) Of the 78 prov iders who report a follow-up mechanism to confirm client referrals, what mechanisms are in place to assess whether referred clients act on referrals?¥ (C414,C414a) Make phone call follow-ups 10 (25.6%) 1 (6.7%) 2 (14.3%) 4 (44.4%) 17 (22.1%) Ask them to come back to clinic 30 (76.9%) 9 (60.0%) 10 (71.4%) 8 (88.9%) 57 (74.0%) Observe in their health passports for records from another facility 28 (71.8%) 12 (80.0%) 12 (85.7%) 5 (55.6%) 57 (74.0%) Discuss cases at District Health Management Team (DHMT) meet ing 0 0 1 (7.1%) 0 1 (1.3%) Home follow-up 3 (7.7%) 0 2 (14.3%) 0 5 (6.5%) Has anything been done to introduce integrated serv ices to community/clients? (C415) Yes 47 (87.0%) 25 (80.7%) 18 (85.7%) 13 (86.7%) 103 (84.4%) No 7 (12.9%) 7 (19.4%) 3 (14.3%) 2 (13.3%) 19 (15.6%) Of the 103 prov iders who report introducing integrated serv ices to community/clients, what has been done to introduce the integrated serv ices to the community/clients?¥ (C415) Shared information with community groups 40 (85.1%) 10 (40.0%) 12 (66.7%) 8 (61.5%) 70 (67.9%) Made or posted announcements in the facility 20 (42.6%) 10 (40.0%) 5 (27.8%) 8 (61.5%) 43 (41.7%) Informed clients directly 43 (91.5%) 24 (96.0%) 16 (88.9%) 11 (84.6%) 94 (91.3%) ¥Categories are NOT mutually exclusive *Numbers in parentheses denote the question number the data were pulled from Annex A. Data Analysis 45 Table A–4: Client demographics within selected facilities, by facility type Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of clients 194 (45.6%) 93 (21.9%) 70 (16.5%) 68 (16.0%) 425 (100%) Age (E101)* 18–30 61 (31.4%) 25 (26.9%) 24 (34.3%) 25 (36.8%) 135 (31.8%) 31–40 83 (43.0%) 42 (45.2%) 28 (40.0%) 23 (33.8%) 176 (41.4%) 41–50 47 (24.4%) 25 (26.9%) 18 (25.7%) 17 (25.0%) 107 (25.2%) ≥51 3 (1.6%) 1 (1.1%) 0 3 (4.4%) 7 (1.6%) Gender (E102) Male 42 (21.7%) 21 (22.6%) 14 (20.0%) 16 (23.5%) 93 (21.9%) Female 152 (78.4%) 72 (77.4%) 56 (80.0%) 52 (76.5%) 332 (78.1%) Education Level (E103) None 24 (12.4%) 7 (7.5%) 7 (10.0%) 0 38 (8.9%) Lower primary 101 (52.1%) 38 (40.9%) 30 (42.9%) 43 (63.2%) 212 (49.9%) Completed primary 37 (19.1%) 15 (16.1%) 12 (17.1%) 9 (13.2%) 73 (17.2%) Lower secondary 18 (9.3%) 17 (18.3%) 11 (15.7%) 14 (20.6%) 60 (14.1%) Higher secondary 12 (6.2%) 13 (13.9%) 10 (14.3%) 2 (2.9%) 37 (8.7%) Tert iary 2 (1.0%) 3 (3.2%) 0 0 5 (1.2%) Tribe/ethnic background (E104) Chewa 67 (34.5%) 15 (16.1%) 11 (15.7%) 17 (25.0%) 110 (25.9%) Yao 24 (12.4%) 10 (10.8%) 6 (8.6%) 1 (1.5%) 41 (9.6%) Ngonde 1 (0.5%) 0 0 1 (1.5%) 2 (0.5%) Tonga 1 (0.5%) 20 (21.5%) 0 29 (42.7%) 50 (11.8%) Ngoni 12 (6.2%) 12 (12.9%) 13 (18.6%) 13 (19.1%) 50 (11.8%) Lomwe 37 (19.1%) 9 (9.7%) 13 (18.6%) 3 (4.4%) 62 (14.6%) Tumbuka 27 (13.9%) 14 (15.1%) 19 (27.1%) 2 (2.9%) 62 (14.6%) Sena 3 (1.6%) 4 (4.3%) 2 (2.9%) 0 9 (2.1%) Other 22 (11.3%) 9 (9.7%) 6 (8.6%) 2 (2.9%) 39 (9.2%) Religion (E105) Catholic 36 (18.6%) 23 (24.7%) 24 (34.3%) 11 (16.2%) 94 (22.1%) Church of Central Africa 38 (19.6%) 19 (20.4%) 18 (25.7%) 8 (11.8%) 83 (19.5%) Anglican 3 (1.6%) 3 (3.2%) 0 3 (4.4%) 9 (2.1%) Seventh Day Adventist 7 (3.6%) 7 (7.5%) 3 (4.3%) 4 (5.9%) 21 (4.9%) Other Christian 69 (35.6%) 21 (22.6%) 10 (14.3%) 38 (55.9%) 138 (32.5%) Muslim 23 (11.9%) 13 (13.9%) 5 (7.1%) 1 (1.5%) 42 (9.9%) Other religion 4 (13.3%) 7 (7.5%) 8 (11.4%) 3 (4.4%) 36 (8.5%) No religion 0 0 2 (2.9%) 0 2 (0.5%) Marital Status (E106) Married/living together 139 (71.7%) 60 (64.5%) 45 (67.1%) 48 (70.6%) 292 (68.7%) Divorced/separated 36 (18.6%) 17 (18.3%) 14 (20.0%) 9 (13.2%) 76 (17.9% Widowed 19 (9.8%) 12 (12.9%) 8 (11.4%) 8 (11.8%) 47 (11.1%) Never married/never lived together 0 4 (4.3%) 1 (1.4%) 3 (4.4%) 8 (1.9%) Place of residence (E107, E107a) Urban 14 (7.2%) 22 (23.7%) 4 (5.7%) 2 (2.9%) 42 (9.9%) Rural 180 (92.8%) 71 (76.3%) 66 (94.3%) 66 (97.1%) 383 (90.1%) Amount of time trav elled to facility (E108) <30 minutes 43 (22.2%) 28 (30.1%) 19 (27.1%) 17 (25.0%) 107 (25.2%) 31–60 minutes 66 (34.0%) 26 (27.9%) 21 (30.0%) 22 (32.4%) 135 (31.8%) >60 minutes 85 (43.8%) 39 (41.9%) 30 (42.9%) 29 (42.7%) 183 (43.1%) Number of children you hav e had (E110) None 9 (4.6%) 7 (7.5%) 2 (2.9%) 4 (5.9%) 22 (5.2%) 1 24 (12.4%) 16 (17.2%) 12 (17.1%) 11 (16.2%) 63 (14.8%) 2-3 86 (44.3%) 44 (47.3%) 30 (42.9%) 22 (32.4%) 182 (42.8%) ≥4 75 (38.7%) 26 (27.9%) 26 (37.1%) 31 (45.6%) 158 (37.2%) Gender of your children who are aliv e (E111) Boys 156 (80.4%) 73 (78.5%) 54 (77.1%) 52 (76.5%) 335 (78.8%) Girls 149 (76.8%) 64 (68.8%) 53 (75.7%) 53 (77.9%) 319 (75.1%) *Numbers in parentheses denote the question number the data were pulled from Integration of Family Planning and HIV Services in Malawi 46 Table A–4.1: Description of clients’ HIV history within selected facilities, by facility type Characteristics Health Centres/Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of HIV-positive clients 194 (46.3%) 93 (22.2%) 69 (16.5%) 63 (15.0%) 419 (100%) How long hav e you been living with HIV?* (E301)** ≤ 12 months 36 (18.6%) 13 (13.9%) 10 (14.5%) 13 (20.6%) 72 (17.2%) 1–5 years 97 (50.0%) 43 (46.2%) 36 (52.2%) 29 (46.0%) 205 (48.9%) 6–10 years 47 (24.2%) 27 (29.0%) 17 (24.6%) 15 (23.8%) 106 (25.3%) ≥11 years 13 (6.7%) 9 (9.7%) 4 (5.8%) 2 (3.2%) 28 (6.7%) Not sure 1 (0.5%) 1 (1.1%) 2 (2.9%) 4 (6.4%) 8 (1.9%) Have you disclosed your HIV status? (E302) Yes 190 (97.9%) 93 (100.0%) 68 (98.6%) 63 (100.0%) 414 (98.8%) No 4 (2.1%) 0 1 (1.5%) 0 5 (1.2%) To whom hav e you disclosed your HIV status?¥ (E302) Spouse 144 (74.2%) 60 (64.5%) 44 (63.8%) 46 (73.0%) 294 (70.2%) Parents1 69 (35.6%) 30 (32.3%) 17 (24.6%) 18 (28.6%) 134 (31.9%) Children 51 (26.3%) 37 (39.8%) 21 (30.4%) 16 (25.4%) 125 (29.8%) Extended family2 121 (62.4%) 70 (75.3%) 46 (66.7%) 42 (66.7%) 279 (66.6%) Friends3 63 (32.5%) 43 (46.2%) 22 (31.9%) 20 (31.7%) 148 (35.3%) Which HIV serv ices have you currently or prev iously accessed at this facility¥(E303a) HCT 35 (18.0%) 12 (12.9%) 14 (20.0%) 15 (24.6%) 76 (18.1%) PMTCT 10 (5.2%) 3 (3.2%) 2 (2.9%) 4 (6.6%) 19 (4.5%) ART 186 (95.9%) 91 (97.9%) 68 (97.1%) 49 (80.3) 394 (94.0%) Other HIV services 4 74 (38.1%) 41 (44.1%) 24 (34.3%) 23 (37.7%) 162 (38.7%) *6 people are not HIV positive **Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive 1Parents includes: mother individually, father individually or both mother and father 2 Extended family includes: siblings 3 Friends includes: pastor 4 Other HIV services includes: HIV monitoring, condom provision, management of OIs, HIV-related nutrition support Annex A. Data Analysis 47 Table A–4.2a: Description of clients’ family planning history within selected facilities, by facility type Characteristics Health Centres/ Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of female respondents 152 72 56 52 332 Are you pregnant now?* (E201)** Yes 9 (5.9%) 2 (2.8%) 3 (5.4%) 3 (5.8%) 17 (5.1%) No 142 (93.4%) 70 (97.2%) 53 (94.6%) 47 (90.4%) 312 (94.0%) Not sure 1 (0.7%) 0 0 2 (3.8%) 3 (0.9%) Total number of women reported being pregnant, 201a) 9 2 3 3 17 Of the 17 women who were pregnant, did they, (201a) Want to become pregnant at the t ime? 2 (22.2%) 1 (50.0%) 1 (33.3%) 0 4 (23.5%) Want to wait until later? 5 (55.6%) 1 (50.0%) 1 (33.3%) 2 (66.7%) 9 (52.9%) Not want any more children? 2 (22.2%) 0 1 (33.3%) 1 (33.3%) 4 (23.5%) Total number of women who reported not being pregnant 143 70 53 49 315 If not pregnant, when do you want your next child? (E201b) In less than two years 14 (9.8%) 9 (12.9%) 3 (5.7%) 2 (4.1%) 28 (8.9%) More than two years later 17 (11.9%) 6 (8.6%) 9 (17.0%) 11 (22.4%) 43 (13.7%) Does not want children 77 (53.8%) 41 (58.6%) 25 (47.2%) 22 (44.9%) 165 (52.4%) Cannot have children 4 (2.8%) 0 0 1 (2.0%) 5 (1.6%) Don’t know 18 (12.6%) 4 (5.7%) 8 (15.1%) 6 (12.2%) 36 (11.4%) Not sure 16 (11.2%) 11 (15.7%) 9 (17.0%) 7 (14.3%) 43 (13.7%) Have you had an operation to avoid hav ing any more children? (E202) Yes 24 (16.8%) 14 (20.0%) 5 (9.4%) 7 (14.3%) 50 (15.9%) No 119 (83.2%) 56 (80.0%) 48 (90.6%) 42 (85.7%) 265 (84.1%) *Total sample of 332 indicates number of women **Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive **There are 2 additional clients in this sample because they were sterilized fairly recently and are still considered as doing something to prevent pregnancies Integration of Family Planning and HIV Services in Malawi 48 Table A–4.2b: Description of clients’ reported family planning services within selected ART clinics, by facility type Characteristics Health Centres/ Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of clients who are potential FP clients (not pregnant, not already sterilized) (E203)* 161 77 62 58 358 Are you currently using any method to av oid pregnancy? (E203) Yes 98 (60.9%) 41 (53.2%) 37 (59.7%) 38 (65.5%) 214 (59.8%) No 63 (39.1%) 36 (46.8%) 25 (40.3%) 20 (34.5%) 144 (40.2%) At the ART clinic, has prov ider ever inquired about fertility intentions or FP? (E209) Yes 32 (19.9%) 16 (20.8%) 7 (11.3%) 23 (39.7%) 78 (21.8%) No 68 (42.2%) 26 (33.8%) 30 (48.4%) 15 (25.9%) 139 (38.8%) No Response 61 (37.9%) 35 (45.5%) 25 (40.3%) 20 (34.5%) 141 (39.4%) Total number of clients reporting that the prov ider has counseled them on FP (E209) 32 16 7 23 78 Of the 78 clients reporting receiv ing FP counseling at the ART clinic, how often has the prov ider counseled you on FP?*** (E209a) Never 0 1 (7.1%) 0 0 1 (1.4%) Rarely 11 (34.4%) 5 (35.7%) 1 (14.3%) 6 (37.5%) 23 (33.3%) Somet imes 5 (15.6%) 2 (14.3%) 1 (14.3%) 3 (18.8%) 11 (15.9%) Often 10 (31.3%) 1 (7.1%) 3 (42.9%) 7 (43.8%) 21 (30.4%) Every t ime 6 (18.8%) 5 (35.7%) 2 (28.6%) 0 13 (18.8%) On av erage after how many visits do the prov iders inquire about your family intentions*** (E209b) Every visit 10 (32.3%) 5 (35.7%) 2 (28.6%) 2 (12.5%) 19 (27.5%) Every second visit 3 (9.7%) 0 0 3 (18.8%) 6 (8.7%) Every third visit 6 (19.4%) 1 (7.1%) 1 (14.3%) 4 (25.0%) 12 (17.4%) Every fourth visit 2 (6.5%) 0 0 2 (12.5%) 4 (5.8%) Every fifth or more visit 10 (32.3%) 8 (57.1%) 4 (57.1%) 5 (31.3%) 27 (39.1%) * Numbers in parentheses denote the question number the data were pulled from ***Info is missing for 9 clients for e209a and e209b, n=69 **There are 2 additional clients in this sample because they were sterilized fairly recently and are still considered as doing something to prevent pregnancies Annex A. Data Analysis 49 Table A–4.2c: Description of clients’ reported family planning services within selected ART clinics, by facility type Characteristics Health Centres/ Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of clients reporting using any short- or long-activing method to av oid pregnancy (E203)* 98 41 37 38 214 What methods are you currently using to av oid pregnancy?¥ (E203a) Pills 3 (3.1%) 2 (4.9%) 3 (8.1%) 1 (2.6%) 9 (4.2%) Male condoms 53 (54.1%) 21 (51.2%) 17 (45.9%) 16 (42.1%) 107 (50.0%) Female condoms 4 (4.1%) 1 (2.4%) 2 (5.4%) 1 (2.6%) 8 (3.7%) Injectables 32 (32.7%) 15 (36.6%) 15 (40.5%) 12 (31.6%) 74 (34.6%) IUD 0 0 0 1 (2.6%) 1 (0.5%) Implants 10 (10.2%0 5 (12.2%) 3 (8.1%) 5 (13.2%) 23 (10.7%) Emergency contraception 0 0 0 0 0 Traditional methods 1 (1.0%) 0 0 0 1 (0.5%) Is the FP method you are using now your method of choice? (E208) Yes 92 (93.9%) 38 (92.7%) 35 (94.6%) 38 (100.0%) 203 (94.9%) No 6 (6.1%) 3 (7.3%) 2 (5.4%) 0 11 (5.1%) At this facility, where do you get your FP method? (E205) Designated FP clinic 31 (31.6%) 13 (31.7%) 18 (48.7%) 21 (55.3%) 83 (38.8%) ART clinic 35 (35.7%) 14 (34.3%) 9 (24.3%) 7 (18.4%) 65 (30.4%) Other locations1 32 (32.7%) 14 (34.2%) 10 (27.0%) 10 (26.3%) 66 (30.8%) When you were giv en your current family planning method, were you told about side effects or problems you might experience? (E206) Yes 52 (53.0%) 18 (43.9%) 19 (51.4%) 25 (65.8%) 114 (53.3%) No 46 (46.9%) 23 (56.1%) 18 (48.7%) 13 (34.2%) 100 (46.7%) When you receiv ed your family planning method were you told what to do if you experienced side effects? (E206a) Yes 59 (60.2%) 25 (60.9%) 18 (48.7%) 25 (65.8%) 127 (59.3%) No 39 (39.8%) 16 (39.0%) 19 (51.4%) 13 (34.2%) 87 (40.7%) Were you told about other FP methods besides the current method you receiv ed? (E207) Yes 70 (72.2%) 32 (78.1%) 25 (69.4%) 31 (81.6%) 158 (73.8%) No 28 (28.6%) 9 (21.9%) 12 (32.4%) 7 (18.4%) 56 (26.2%) Total number of clients reporting that they were told about other FP methods besides the one they receiv ed (E207) 70 32 25 31 158 What other FP methods besides the one you were giv en were you told about?¥ (E207a) Pills 52 (74.3%) 23 (71.9%) 22 (88.0%) 29 (93.6%) 129 (81.6%) Male condoms 51 (72.9%) 20 (62.5%) 20 (80.0%) 29 (93.6%) 120 (75.9%) Female condoms 44 (62.9%) 24 (75.0%) 16 (64.0%) 28 (90.3%) 112 (70.9%) Injectables 44 (62.9%) 21 (65.6%) 19 (76.0%) 26 (83.9%) 110 (69.6%) IUD 47 (67.1%) 21 (65.6%) 18 (72.0%) 27 (87.1%) 113 (71.5%) Implants 42 (60.0%) 19 (59.4%) 16 (64.0%) 26 (83.9%) 103 (65.2%) Female sterilization 20 (28.6%) 5 (15.6%) 8 (32.0%) 10 (32.3%) 43 (27.2%) Male sterilization 9 (12.9%) 3 (9.4%) 7 (28.0%) 6 (19.4%) 25 (15.8%) Emergency contraception 6 (8.6%) 3 (9.4%) 4 (16.0%) 5 (16.1%) 18 (11.4%) * Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive 1Other Locations: ANC/PMTCT clinic, OPD, IPD, HCT **There are 2 additional clients in this sample because they were sterilized fairly recently and are still considered as doing something to prevent pregnancies Integration of Family Planning and HIV Services in Malawi 50 Table A–4.3: FP-HIV integration as described by clients within selected facilities, by facility type Characteristics Health Centres/ Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of clients 194 93 70 68 425 What serv ices did you receive today? (E401)* FP 8 (4.1%) 1 (1.1%) 6 (8.6%) 4 (5.9%) 19 (4.5%) ART 167 (86.1%) 87 (93.6%) 55 (78.6%) 46 (67.7%) 355 (83.5%) Other HIV services1 19 (9.8%) 5 (5.4%) 9 (12.9%) 18 (26.5%) 51 (12.0%) If you came to the clinic for ART and other HIV serv ices (n=406), did anyone ask if you wanted to have more children and offer you family planning? (E401b) N=186 N=92 N=64 N=64 N=406 Yes 21 (11.3%) 13 (14.1%) 8 (12.5%) 14 (21.9%) 56 (13.8%) No 165 (88.7%) 79 (85.9%) 56 (87.5%) 50 (78.1%) 350 (86.2%) Number of clients who receiv ed multiple serv ices 31 13 14 18 76 How and where were the multiple services you receiv ed today? (E402) Received all services in the same room by same provider 22 (70.9%) 5 (38.5%) 9 (64.3%) 12 (66.7%) 48 (63.2%) Received all services by different providers in same clinic 1 (3.2%) 4 (30.8%) 1 (7.1%) 3 (16.7%) 9 (11.8%) Received services in different rooms in same facility 8 (25.8%) 4 (30.8%) 4 (28.6%) 3 (16.7%) 19 (25.0%) Total number of clients who reported not receiv ing all the serv ices they came in for (E403) 13 10 1 7 31 Reasons for not receiv ing all the serv ices you came in for today¥ (E403a) Service not provided at this facility 4 (30.8%) 3 (30.0%) 0 2 (28.6%) 9 (29.0%) I came outside operating hours 3 (23.1%) 3 (30.0%) 0 2 (28.6%) 8 (25.8%) No health provider 1 (7.7%) 0 1 (100.0%) 0 2 (6.5%) Health provider did not have enough t ime 2 (15.4%) 1 (10.0%) 0 1 (14.3%) 4 (12.9%) I did not have enough t ime 1 (7.7%) 0 0 0 1 (3.2%) Shortage of drugs 2 (15.4%) 2 (20.0%) 0 1 (14.3%) 5 (16.1%) Referred to another facility 0 1 (10.0) 0 1 (14.3%) 2 (6.5%) Of the two clients who were referred to another facility, did they receiv e adequate information on the referred facility for the serv ices you wanted? (E403b) Yes 0 1 (100.0%) 0 0 1 (50.0%) No 0 0 0 1 (100.0%) 1 (50.0%) * Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive 1Other HIV services includes: HCT, PMTCT, HIV monitoring, Management of OIs, HIV-related nutrition support Annex A. Data Analysis 51 Table A–4.4: Satisfaction of FP-HIV services as described by clients within selected facilities, by facility type Characteristics Health Centres/ Posts N (%) Public Hospitals N (%) CHAM Missions N (%) Integrated Health Centres N (%) Total N (%) Total number of clients (E404)* 194 93 70 68 425 How would you prefer to get the serv ices at this facility? (E404) Same clinic, same day 190 (97.9%) 91 (97.9%) 67 (95.7%) 64 (94.1%) 412 (96.9%) Same facility, different clinic, same day 4 (2.1%) 2 (2.2%) 3 (4.3%) 4 (5.9%) 13 (3.1%) Are you satisfied with the serv ices you receiv ed in relation to the time spent waiting? (E405) Yes 168 (86.6%) 78 (83.9%) 66 (94.3%) 60 (88.2%) 372 (87.5%) No 26 (13.4%) 15 (16.1%) 4 (5.7%) 8 (11.8%) 53 (12.5%) Total number of clients not satisfied with serv ices 26 (49.1%) 15 (28.3%) 4 (7.5%) 8 (15.1%) 53 Reasons for not being satisfied with the serv ices you receiv ed today¥ (E405a) Did not receive all services I came for 6 (23.1%) 4 (26.7%) 1 (25.0%) 1 (12.5%) 12 (22.6%) Waited too long 13 (50.0%) 6 (40.0%) 3 (75.0%) 3 (37.5%) 25 (47.2%) No health provider 0 1 (6.7%) 0 2 (25.0%) 3 (5.7%) Shortage of drugs 1 (3.9%) 1 (6.7%) 0 0 2 (3.8%) Staff rude and unkind 1 (3.9%) 0 0 1 (12.5%) 2 (3.8%) Consultation was too short 5 (19.2%) 3 (20.0%) 0 0 8 (15.1%) Lack of privacy 0 0 0 1 (12.5%) 1 (1.9%) Total number of clients who responded to time preference (E406) 194 93 70 86 425 Time preference in relation to serv ices (E406) Prefer to wait for a longer t ime to get mult iple services per visit 178 (91.8%) 79 (84.9%) 65 (92.9%) 60 (88.2%) 382 (89.9%) Prefer to wait for a shorter time to get one service per visit Not sure 12 (6.2%) 4 (2.1%) 10 (10.8%) 4 (4.3%) 4 (5.7%) 1 (1.4%) 7 (10.3%) 1 (1.5%) 33 (7.8%) 10 (2.4%) Benefits of receiv ing HIV and FP serv ices at the same time¥ (E407) Make fewer t rips to facility 151 (77.8%) 73 (78.5%) 56 (80.0%) 50 (73.5%) 330 (77.6%) Reduced t ransportation costs 88 (45.4%) 39 (41.9%) 30 (42.9%) 25 (36.8%) 182 (42.8%) Reduced waiting t ime 86 (44.3%) 44 (47.3%) 37 (52.8%) 35 (51.5%) 202 (47.5%) Efficient way to access several services 45 (23.2%) 23 (24.7%) 24 (34.3%) 23 (33.8%) 115 (27.1%) Reduces stigma toward accessing HIV services 14 (7.2%) 3 (3.2%) 3 (4.3%) 10 (14.7%) 30 (7.1%) Reduces stigma toward accessing FP services 3 (1.6%) 4 (4.3%) 2 (2.9%) 1 (1.5%) 10 (2.4%) Don’t know 9 (4.6%) 2 (2.2%) 1 (1.4%) 2 (2.9%) 14 (3.3%) Disadv antages of receiv ing HIV and FP serv ices at the same time¥ (E408) Increased waiting t ime 77 (39.7%) 37 (39.8%) 29 (41.4%) 22 (32.4%) 165 (38.8%) Decreased time with provider due to increased workload 20 (10.3%) 13 (13.9%) 11 (15.7%) 15 (22.1%) 59 (13.9%) Fear of st igma and discrimination 28 (14.4%) 6 (6.5%) 8 (11.4%) 11 (16.2%) 53 (12.5%) Fear of loss of confidentiality 40 (20.6%) 13 (13.9%) 13 (18.6%) 13 (19.1%) 79 (18.6%) Decreased quality of services 6 (3.1%) 2 (2.2%) 3 (4.3%) 6 (8.8%) 17 (4.0%) Embarrassment to discuss HIV and/or FP with provider from same village 11 (5.7%) 8 (8.6%) 5 (7.1%) 1 (1.5%) 25 (5.9%) Don’t know 44 (22.7%) 17 (18.3%) 15 (21.4%) 18 (26.5%) 94 (22.1%) * Numbers in parentheses denote the question number the data were pulled from ¥Categories are NOT mutually exclusive Integration of Family Planning and HIV Services in Malawi 52 Table A-4.5: Client flow analysis table ART Waiting Room ART Registration ART Provider Room FP provider Room Facility name Average time Range Average time Range Average time Range Number of clients Average time Range Health centre/post Mpherembe Health Centre 37 2-95 15 1-32 4 2-14 0 - - Engucwini Health Post 96 7-194 5 0-23 8 3-35 0 - - Thunduwike Health Centre 91 15-213 13 3-21 32 9-50 0 - - Manyamula Health Centre 51 10-154 28 0-89 7 4-16 0 - - Lighthouse Clinic 27 6-71 23 2-118 36 1-122 0 - - Lumbadzi Health Centre 43 8-112 5 1-10 5 1-18 0 - - Malingunde Health Centre 29 1-101 43 n/a* 19 2-98 0 - - Nkanda Health Centre 22 5-37 9 5-17 11 2-28 0 - - Kochilira Health Centre 63 13-204 46 n/a* 18 1-98 0 - - Kapanga Health Centre 11 2-19 73 n/a* 8 2-20 0 - - Nkhwazi Health Centre 3 2-4 20 7-34 4 0-14 0 - - Golomoti Health Centre 42 0-99 19 6-36 5 0-16 0 - - Madziabango Health Centre 99 35-188 - - 6 3-12 0 - - Mimosa Health Centre 44 11-70 - - 21 3-56 0 - - Lujeri Health Centre 31 5-125 - - 13 3-50 0 - - Chisitu Health Centre 154 1-351 - - 4 1-16 0 - - Asaalam Clinic 4 0-9 - - 5 0-17 1 3 n/a* Namwera Health Centre 29 5-40 - - 15 1-36 0 - - Phirilongwe Health Centre 112 11-174 - - 14 2-94 0 - - Public hospitals Chintheche Rural Hospital 120 1-230 58 1-165 28 0-86 0 - - Nkhata-Bay District Hospital 51 7-99 13 1-34 14 3-93 0 - - Monkey-Bay Community Hospital 52 20-76 - - 4 1-9 0 - - Mangochi District Hospital 37 18-91 3 n/a* 9 1-24 0 - - Mchinji District Hospital 60 9-118 - - 16 7-40 1 27 n/a* Dedza District Hospital 102 7-188 - - 3 0-10 0 - - Mulanje District Hospital 38 1-177 5 0-23 9 2-26 9 2 1-5 Mzuzu Central Hospital 59 4-144 6 1-18 10 1-21 0 - - Queen Elizabeth Central Hospital 3 n/a* 45 25-65 4 n/a* 0 - - CHAM Mabiri Health Centre 61 9-151 4 0-15 13 0-64 0 - - Katete Community Hospital 34 6-120 13 2-33 13 2-47 0 - - Nkhoma Mission Hospital 31 12-87 - - 5 1-16 0 - - Bembeke Health Centre 36 11-48 - - 7 2-16 0 - - Lumbira Health Centre 88 45-136 53 9-98 35 7-137 0 - - Mlambe Mission Hospital 8 0-15 - - 5 0-17 0 - - Mulanje Mission Hospital 171 75-290 40 n/a* 18 2-62 1 2 n/a* Integrated health centres Mpamba Health Centre 185 n/a* - - 9 n/a* 2 15 4-26 Mzenga Health Centre 20 n/a* - - 9 6-15 0 - - Kande Health Centre 64 11-115 - - 9 1-28 0 - - Nkhata-Bay BLM 4 n/a* - - 4 3-6 3 13 7-22 Ntakataka Health Centre 29 4-70 - - 6 2-17 0 - - Lobi Health Centre 25 2-113 87 8-214 3 1-11 0 - - *N/A as only one client reported 53 ANNEX B. CALCULATIONS FOR CLIENT EXIT INTERVIEWS n = [4(r)(1 − r)(f)(1.1)][(0.12𝑟)2(𝑝)(𝑛ℎ)] Calculations for client exit interviews Where, • n is a required sample size, expressed as number of clients across the district • 4 is a factor to achieve the 95% level of confidence • r is the predicted or anticipated prevalence (coverage rate) of indicator, unmet need for FP (26%) • 1.1 is a factor necessary to raise the sample size by 10% for non-response • f is the shortened symbol for deff (designed effect) =1.4 • 0.12r is a margin of error to be tolerated at 95% level of confidence, defined as 12% of r (relative sampling error of r) • p is the proportion of the total population upon which indicator, r, is based • nh is the average household size=5 54 ANNEX C. QUESTIONNAIRES ADMINISTERED AT FACILITIES Unique ID: ______ Appendix C1: Facility Audit, in English Name of District: Date (Day/Month/Year): Name of facility: Name of data collector: Category of facility: The data collector will fill the form by observing the facility and services being provided after receiving consent from the facility-in-charge. No. Question Categories Skip pattern Instructions General Observations A101 Is there a sign with the name of the health facility v isible within the premises? Yes ___ No ___ A102 Are the operating hours of the facility noted at the entrance? Yes ___ No ___ A103 Is there a watchman at the facility entrance? Yes ___ No ___ A103a Is the watchman seen to be prov iding information to patients? Yes ___ No ___ Out-patient Department (OPD) A201 Is there an OPD/ general reception counter at the facility? Yes ___ No ___ If No, skip to A202 A201a If Yes, is there a staff member present managing the reception? Yes ___ No ___ A201b If Yes, did you notice a time when the OPD/general reception was left unstaffed? ____ : ____ Yes ___ No ___ Bathroom breaks are allowed. A202 Is there a patient/client waiting area at the OPD? Yes ___ No ___ If No, skip to A203 A202a If Yes, is the area generally clean with adequate seating? Yes ___ No ___ If one of the two parts to this question is negativ e, mark it as no A203 Which of the serv ices offered at the facility are noted near the registration desk or somewhere easily v isible in the OPD waiting area? (Tick all that apply) Out-patient department ___ ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ HIV serv ices ___ Others, specify _____________ None____ Tick those departments whose serv ices are mentioned. Cross those departments whose serv ices exist but are not mentioned. Write N/A if serv ice does not exist at facility. A204 Which of the following departments hav e their operating hours clearly noted at the OPD? (Tick all that apply) Out-patient department ___ ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty)___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ Tick those departments whose operating hours are noted at OPD. Cross those departments that exist at facility but whose operating hours are not mentioned at OPD. Write N/A if serv ice does not exist at Annex C. Questionnaires Administered at Facilities 55 No. Question Categories Skip pattern Instructions HIV serv ices ___ Others, specify _____________ None___ facility. A205 How many health providers are working in the OPD? ___________ Insert number of prov iders A206 Are there IEC messages about HIV at the OPD? Yes ___ No ___ If no, skip to A207 A206a If Yes, what are the messages about? (Tick all that apply) HIV prev ention ___ ART adherence ___ Importance of HIV testing ___ Av ailability of HIV serv ices ___ Signs of opportunistic infections ___ HIV-related nutrition ___ Others, specify _____________ A207 Are there IEC messages on FP at the OPD? Yes ___ No ___ If no, skip to 208 A207a If yes, what are the main messages about FP? (Tick all that apply) FP Methods ___ Importance of using FP methods ___ Av ailability of FP methods ___ Where to get FP methods Others, specify ______________ A208 Is the setup of the prov ider’s consultation room appropriate and comfortable for seeing patients? (Tick all that apply) The prov ider and patient have their respectiv e seating areas ___ The room is well-lighted ___ The room is clean ___ The room is quiet enough for prov ider and client to communicate with ease ___ The room allows for adequate priv acy ___ There are adequate medical supplies in the room, such as an examination bed, stethoscope, priv acy screen, etc. ___ Other observ ations, specify _________________________ None ___ Could not observ e the providers consultation room ___ Try to observ e one where some sort of HIV serv ices are being prov ided Other Departments A301 Are there v isible and clear directions to v arious health facility departments across the health facility? (Tick all that apply) Out-patient department ___ ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ ART clinic ___ Others, specify _____________ None ___ Tick those departments who hav e clear directions. Cross those departments that don’t have clear signs. Write N/A if serv ice does not exist at facility. A302 Are hospital departments clearly labeled in the local language? (Tick all that apply) Out-patient department ___ ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ ART clinic ___ Others, specify _____________ None ___ Tick those departments who are clearly labeled. Cross those departments that are not clearly labeled. Write N/A if serv ice does not exist at facility. Integration of Family Planning and HIV Services in Malawi 56 No. Question Categories Skip pattern Instructions A303 Are the operating hours of the v arious departments clearly noted in front of the respectiv e departments? Out-patient department ___ ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/ surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ ART clinic ___ Others, specify _____________ None ___ Tick those departments whose operating hours are clearly labeled. Cross those departments whose operating hours are not clearly labeled. Write N/A if serv ice does not exist at facility. A304 Which departments have an additional reception/sign-in area for their clients? ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ ART clinic ___ Others, specify _____________ None ___ Tick those departments who hav e additional reception/sign-in area. Cross those departments who don’t have an additional reception/sign-in area. Write N/A if serv ice does not exist at facility. A305 Which departments have a separate waiting area for their clients? (Tick all that apply) ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ ART clinic ___ Others, specify _____________ None ___ If none, skip to A401. Tick those departments who hav e a separate waiting area. Cross those departments who don’t have a separate waiting area. Write N/A if serv ice does not exist at facility. A305a If Yes, are the indiv idual waiting areas are generally clean? (Y/N) ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ ART clinic ___ Others, specify _____________ None ___ Others, specify _____________ Mark yes or no for departments that are ticked above. Tick those departments who hav e a clean waiting area. Cross those departments whose waiting areas are not clean. Write N/A if waiting area does not exist at facility. A305b If Yes, do the indiv idual waiting areas hav e adequate seating? (Y/N) ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (ward) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Family Planning ___ ART clinic ___ Others, specify _____________ Mark yes or no for departments that are ticked above. Tick those departments who hav e a waiting area with adequate seating. Cross those departments whose waiting areas do not hav e adequate seating. Write N/A if Annex C. Questionnaires Administered at Facilities 57 No. Question Categories Skip pattern Instructions None ___ Others, specify _____________ waiting area does not exist at facility. HIV Counseling and Testing (HCT) Clinic A401 Are HCT serv ices provided at this facility? Yes ___ No ___ If No, skip to A501 You may ask someone within the facility to determine if HCT serv ices are being prov ided. Preferably a prov ider or receptionist. A402 Where are HCT serv ices provided? Designated HCT clinic ___ Designated HCT room within OPD ___ Out-patient department ___ ANC/PMTCT ___ In-patient department (ward) ___ Family Planning clinic ___ ART clinic ___ Others, specify _____________ None were observ ed ___ If designated HCT clinic or room marked, proceed to A403. Otherwise, skip to A501. A403 Is there adequate waiting area for patients/clients at the HCT clinic? Yes ___ No ___ If No, skip to A404 A403a If Yes, is the area generally clean? Yes ___ No ___ A403b If Yes, does the area generally hav e adequate seating? Yes ___ No ___ A404 Is the setup of the prov ider’s room appropriate and comfortable for seeing patients? (Tick all that apply) - The prov ider and patient have their respectiv e seating areas ___ - The room is well-lighted ___ - The room is clean ___ - The room is quiet enough for prov ider and client to communicate with ease ___ - The room allows for protection of auditory privacy ___ - The room allows for protection of v isual privacy ___ - There are adequate medical supplies in the room, such as an examination bed, stethoscope, priv acy screen, etc. ___ Other observ ations, specify _________________________ -None ___ A405 How many providers are working at the HCT clinic? _________ Insert number of prov iders. Will need to ask, preferably a prov ider or receptionist A406 What is the cadre of prov iders working at the HCT clinic? (Tick all that apply) Medical Doctor ___ Registered Nurse/Midwife ___ Clinical Officer ___ Nurse Midwife Technician ___ Medical Assistant ___ Auxiliary Nurse ___ Patient Attendant ___ HSA ___ HIV Counselor ___ Others, specify_____________ None ___ Could not observ e ___ Will need to ask, preferably a prov ider or receptionist. A407 What FP commodities and supplies were noted as being av ailable at the HCT clinic? (Tick all that apply) Pills ___ Male condoms ___ Female condoms ___ Injectables ___ IUD ___ Implants ___ Female sterilization___ Male sterilization ___ Emergency contraception ___ Others, specify _____________ Check the register for this information. Integration of Family Planning and HIV Services in Malawi 58 No. Question Categories Skip pattern Instructions None ___ Unable to observe ___ A408 How are data on use of FP commodities being recorded at the HCT clinic? Extra columns added in the HCT register ___ Separate FP register maintained ___ No notification made in register ___ Others, specify _________________________ Could not check register ___ Check the register for this information. A409 Are IEC messages about HIV seen at the HCT clinic? Yes ___ No ___ If no, skip to A410 A409a If Yes, what are the messages about? (Tick all that apply) HIV prev ention ___ Role of FP in HIV prev ention ___ ART adherence ___ Importance of testing ___ Av ailability of HIV serv ices ___ Signs of opportunistic infections ___ HIV related nutrition ___ Others, specify _____________ A410 Are IEC messages on FP seen at the HCT clinic? Yes ___ No ___ If No, skip to A411 A410a If yes, what are the main messages about FP? (Tick all that apply) FP Methods ___ Benefits of FP for PLHIV ___ Importance of using FP methods ___ Av ailability of FP methods ___ Where to get FP methods Others, specify ____________ A411 Are HIV policies/guidelines av ailable at the HCT clinic? Yes ___ No ___ A412 Are FP policies/guidelines av ailable at the HCT clinic? Yes ___ No ___ ART Clinic A501 Are ART serv ices prov ided at this facility? Yes ___ No ___ If No, skip to A601 You may ask someone within the facility to determine if ART serv ices are being prov ided. Preferably a prov ider or receptionist. A502 Where are ART serv ices prov ided? Designated ART clinic ___ Designated ART room within OPD ___ Out-patient department ___ ANC/PMTCT ___ In-patient department (ward) ___ Family Planning clinic ___ Others, specify _____________ None were observ ed __ If designated ART clinic or room marked, proceed to A503. Otherwise, skip to A601. A503 Is there adequate waiting area for patients/clients at the ART clinic? Yes ___ No ___ If No, skip to A504 A503a If Yes, is the area generally clean? Yes ___ No ___ A503b If Yes, does the area generally hav e adequate seating? Yes ___ No ___ A504 Is the setup of the prov ider’s room appropriate and comfortable for seeing patients? (Tick all that apply) - The prov ider and patient have their respectiv e seating areas ___ - The room is well-lighted ___ - The room is clean ___ - The room is quiet enough for prov ider and client to communicate with ease ___ - The room allows for adequate priv acy ___ - There are adequate medical supplies in the room, such as an examination bed, stethoscope, Annex C. Questionnaires Administered at Facilities 59 No. Question Categories Skip pattern Instructions priv acy screen, etc. ___ - Other observ ations, specify _________________________ - None ___ Other observ ations, specify _________________________ A505 How many providers are working at the ART clinic? _________ Insert number of prov iders. Will need to ask, preferably a prov ider or receptionist A506 What is the cadre of prov iders working at the ART clinic? Medical Doctor ___ Registered Nurse/Midwife ___ Clinical Officer ___ Nurse Midwife Technician ___ Medical Assistant ___ Auxiliary Nurse ___ Patient Attendant ___ HSA ___ HIV Counselor ___ Others, specify_____________ None ___ Could not observ e ___ A507 What FP commodities and supplies were noted as being av ailable at the ART clinic? Pills ___ Male condoms ___ Female condoms ___ Injectables ___ IUD ___ Implants ___ Female sterilization___ Male sterilization ___ Emergency contraception ___ Others, specify _____________ None ___ Unable to observe ___ If none, or pills and/or condoms noted, skip A509. A508 How are data on use of FP commodities being recorded at the ART clinic? Extra columns added in the ART register ___ Separate FP register maintained ___ No notification made in register ___ Others, specify _________________________ Could not check register ___ A509 Are IEC messages about HIV seen at the ART clinic? Yes ___ No ___ If No, skip to A510 A509a If Yes, what are the messages about? HIV prev ention ___ Role of FP in HIV prev ention___ ART adherence ___ Importance of testing ___ Av ailability of HIV serv ices ___ Signs of opportunistic infections ___ HIV-related nutrition ___ Others, specify _____________ A510 Are IEC messages on FP seen at the ART clinic? Yes ___ No ___ If No, skip to A511 A510a If yes, what are the main messages about FP? FP Methods ___ Benefits of FP for PLHIV ___ Importance of using FP ___ methods ___ Av ailability of FP methods ___ Where to get FP methods Others, specify ______________ A511 Are HIV policies/guidelines seen at the ART clinic? Yes ___ No ___ A512 Are FP policies/guidelines seen at the ART clinic? Yes ___ No ___ FP Clinic A601 Are FP serv ices prov ided at this Yes ___ If No, skip to You may ask Integration of Family Planning and HIV Services in Malawi 60 No. Question Categories Skip pattern Instructions facility? No ___ A701 someone within the facility to determine if FP serv ices are being prov ided. Preferably a prov ider or receptionist. A602 Where are FP serv ices provided? Designated FP clinic ___ Designated FP room within OPD ___ Out-patient department ___ ANC/PMTCT ___ In-patient department ___ ART clinic ___ Others, specify _____________ If designated FP clinic or room marked, proceed to A603. Otherwise, skip to A701. A603 Is there adequate waiting area for patients/clients at the FP clinic? Yes ___ No ___ If No, skip to A604 A603a If Yes, is the area generally clean? Yes ___ No ___ A603b If Yes, does the area generally hav e adequate seating? Yes ___ No ___ A604 Is the setup of the prov ider’s room appropriate and comfortable for seeing patients? (Tick all that apply) - The prov ider and patient have their respectiv e seating areas ___ - The room is well-lighted ___ - The room is clean ___ - The room is quiet enough for prov ider and client to communicate with ease ___ - The room allows for adequate priv acy ___ - There are adequate medical supplies in the room, such as an examination bed, stethoscope, priv acy screen, etc. ___ - Other observ ations, specify _________________________ - None ___ A605 How many providers are working at the FP clinic? _________ Insert number of prov iders. Will need to ask, preferably a prov ider or receptionist A606 What is the cadre of prov iders working at the FP clinic? Medical Doctor ___ Registered Nurse/Midwife ___ Clinical Officer ___ Nurse Midwife Technician ___ Medical Assistant ___ Auxiliary Nurse ___ Patient Attendant ___ HSA ___ HIV Counselor ___ Others, specify_____________ None ___ Could not observ e ___ A607 What FP commodities and supplies were noted as being av ailable at the FP clinic? (Tick all that apply) Pills ___ Male condoms ___ Female condoms ___ Injectables ___ IUD ___ Implants ___ Female sterilization___ Male sterilization ___ Emergency contraception ___ Others, specify _____________ None ___ A608 Are HIV serv ices prov ided at the FP clinic? Yes ___ No ___ If No, skip to A609 A608a If yes, what HIV serv ices are provided at the FP clinic? (Tick all that apply) HCT ___ PMTCT ___ HIV monitoring ___ ART ___ Annex C. Questionnaires Administered at Facilities 61 No. Question Categories Skip pattern Instructions Condom prov ision___ Management of OIs ___ NutritionHIV-related nutrition support ___ Others, specify ______________ A609 How are data on provision of HIV serv ices being recorded at the FP clinic? Extra columns added in the FP register ___ Separate HIV register maintained ___ No notification made ___ Others, specify _________________________ Could not check register ___ A610 Which HIV serv ices are included in the FP client register? (Tick all that apply) HCT ___ PMTCT ___ HIV monitoring ___ ART ___ Condom prov ision___ Management of OIs ___ HIV-related nutrition support ___ Others, specify ______________ None ___ A611 Are IEC messages about HIV seen at the FP clinic? Yes ___ No ___ If No, skip to A612 A611a If Yes, what are the messages about? HIV prev ention ___ Role of FP in HIV prev ention ___ ART adherence ___ Importance of testing ___ Av ailability of HIV serv ices ___ Signs of opportunistic infections ___ HIV-related nutrition ___ Others, specify _____________ A612 Are IEC messages on FP seen at the FP clinic? Yes ___ No ___ If No, skip to A613 A612a If yes, what are the main messages about FP? FP Methods ___ Benefits of FP for PLHIV ___ Importance of using FP ___ methods ___ Av ailability of FP methods ___ Where to get FP methods Others, specify ______________ A613 Are HIV policies/guidelines seen at the FP clinic? Yes ___ No ___ A614 Are FP policies/guidelines seen at the FP clinic? Yes ___ No ___ Pharmacy A701 Is there a pharmacy at this facility? Yes ___ No ___ A702 Was the pharmacy open and av ailable for observ ation on the day of the v isit? Yes ___ No ___ A703 Is there awaiting area for patients/clients at the pharmacy? Yes ___ No ___ If No, skip to A704 A703a If Yes, is the area generally clean? Yes ___ No ___ A703b If Yes, does the area hav e adequate seating? Yes ___ No ___ A704 Is there adequate privacy for clients at the pharmacy? Yes ___ No ___ A705 What FP commodities and supplies are av ailable at the pharmacy? None ___ Pills ___ Male condoms ___ Female condoms ___ Injectables ___ Emergency contraception ___ Others, specify _____________ None ___ Could not speak to pharmacist __ Ask the pharmacist. A706 What HIV drugs and supplies are av ailable at the pharmacy? HCT kits ___ ARVs ___ Ask the pharmacist. Integration of Family Planning and HIV Services in Malawi 62 No. Question Categories Skip pattern Instructions HIV nutritional supplements ___ Drugs for opportunistic infections (cotrimoxazole/bactrim) ___ Others, specify _____________ None ___ A707 Are IEC messages about HIV seen at the pharmacy? Yes ___ No ___ If no, skip to A708 A707a If Yes, what are the messages about? HIV prev ention ___ Role of FP in HIV prev ention ___ ART adherence ___ Importance of testing ___ Av ailability of HIV serv ices ___ Signs of opportunistic infections ___ HIV-related nutrition ___ Others, specify _____________ None ___ A708 Are IEC messages on FP seen at the pharmacy? Yes ___ No ___ If no, skip A801 A708a If yes, what are the main messages about FP? FP Methods ___ Benefits of FP for PLHIV ___ Importance of using FPmethods ___ Av ailability of FP methods ___ Where to get FP methods Others, specify ______________ None ___ Annex C. Questionnaires Administered at Facilities 63 No. Question Instructions General Observations A801 a What are your general observations of the facility? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ A801 b What are your general observations of the services being provided? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ E502 What are some suggestions you have for improving services at this facility? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Integration of Family Planning and HIV Services in Malawi 64 Unique ID: ______ Appendix C2: Questionnaire Guide, in English, Administered to Facility In-charge City/Town/Village: Date (Day/Month/Year): District: Name of data collector: Name of facility: Location of facility (circle most appropriate): Rural/ Urban/ Semi-urban No Question Categories Skip pattern Instructions Health Facility Characteristics B101 What type of facility is this? (Tick one appropriate answer) Gov ernment Central Hospital ___ Gov ernment District Hospital ___ Gov ernment Health Centre ___ Gov ernment health post ___ CHAM Hospital ___ CHAM Health Centre ___ BLM ___ Other, specify _________________ Single response. If you’re not sure, leav e blank. It will be filled by data entry team. Facility In-Charge Demographic Characteristics B201 How old were you on your last birthday? ______ Years numeric B202 What is your sex? (Tick the appropriate answer) Male ___ Female ___ Single response B203 What is your current occupation? (Tick one appropriate answer) Medical specialist ___ Medical Doctor ___ Registered Nurse/Midwife ___ Clinical Officer ___ Nurse/Midwife Technician ___ Medical Assistant ___ Other Specify________________ If medical specialist, answer B203a Single response B203a If Medical Specialist, what is your area of specialty? Internal medicine ___ Obstetrics and Gynecology ___ Surgery ___ Pediatrics ___ Orthopedics ___ Others, specify _____________________ Single response B204 How long hav e you worked since you last graduated? (Circle the most appropriate denomination of time) ________ Weeks/ Months/ Years Numeric + circle appropriate time denomination B205 For how long hav e you worked as an in-charge at this facility? (Circle the most appropriate denomination of time) _______ Weeks/ Months/ Years Numeric + circle appropriate time denomination Facility In-Charge Training B301 Have you receiv ed any training in prov iding the following FP serv ices? (Tick all that apply) Pre-serv ice FP ___ In-Service Short-acting methods ___ Implant (Jadelle, Implanon, norplant) ___ IUD (loupu) ___ Female sterilization ___ Male sterilization ___ Other, specify ___________________ None noted ___ If you mark “none noted”, skip to B302. Multiple responses selected. First, wait for prov ider to tell you their training and ask about other options. Mark none noted if prov ider didn’t respond to any above. B301a If Yes, when was the last time you were trained in prov iding the FP serv ices? FP Training Month / Year Pre-serv ice FP ____ / ______ Short-acting methods ____ / ______ Implant ____ / ______ IUD ____ / ______ BTL ____ / ______ Indicate month (for e.g., 06) and year (for e.g., 2005). Annex C. Questionnaires Administered at Facilities 65 No Question Categories Skip pattern Instructions Vasectomy ____ / ______ Other ____ / ______ B302 Have you receiv ed any training in prov iding the following HIV serv ices? (Tick all that apply) HCT ___ PMTCT ___ HIV monitoring ___ ART ___ Condom prov ision ___ Management of OIs ___ HIV-related nutrition support ___ Others, specify __________________ None noted ___ If you mark “none noted”, skip to B303. If prov ider hasn’t receiv ed any training, mark none noted. If prov ider says Option B or Option B+, tick PMTCT. B302a If Yes, when was the last time you were trained in prov iding the HIV serv ices? HIV Training Month / Year HCT ____ / ______ PMTCT ____ / ______ HIV monitoring ____ / ______ ART ____ / ______ Management of OIs ____ / ______ HIV-related nutrition support ____ / ______ Other ____ / ______ Indicate month (for e.g., 06) and year (for e.g., 2005). B303 Have you been trained in FP / Sexual and Reproductive Health (SRH), and HIV integration? Yes ___ No ___ Not Sure ___ If No, GO TO B401 Single response B303a If Yes, when was the last time you were trained? Month / Year ____ / ______ B303b Who prov ided the FP-HIV integrated training? (Tick all that apply) During medical/nursing training ___ MoH Reproductive Health Unit ___ MoH HIV Unit ___ UNFPA ___ SSDI-Jhpiego ___ BLM ___ Outside Malawi ___ Other, specify ____________________________ Multiple responses Health Services B401 What serv ices are provided at this facility? (Tick all that apply) Out-patient department ___ ANC ___ Labour & Deliv ery ___ Postnatal___ Under-five clinic ___ In-patient department (wards) ___ Emergency room (casualty) ___ Operating room (theater/surgery) ___ Laboratory ___ X-Ray and Diagnostics ___ Others, specify ________________________ In-patient department refers to wards. Emergency room refers to casualty.Operating room refers to operation theater. B402 What family planning services do you prov ide at this facility? (Tick all that apply, except if you select none) Reproductive Decision counseling ___ Pills ___ Male condoms ___ Female condoms ___ Injectables (Depo) ___ IUD (loupu, copper-T ) ___ Implants (Jadelle, Implanon, Norplant) ___ Female sterilization___ Male sterilization ___ Emergency contraception ___ Others, specify ________________________ None ___ If none, skip to B405. If no serv ices, select “none” only. Moon beads or cycle beads are to be added under other. FP counseling also includes a category of serv ice under “other”. B403 Where can clients receiv e family planning serv ices at this facility? (Tick all that apply) FP Clinic ___ Out-patient department ___ HCT Clinic ___ ART Clinic ___ PMTCT/ANC clinic___ Deliv ery ___ Postnatal ___ Under-five clinic ___ Others, specify ______________________ If FP clinic ticked, then answer B403a and B403b. Otherwise, skip to B404. The interv iewer will ask about the remaining entry points, once the respondent mentions entry points on their own. Integration of Family Planning and HIV Services in Malawi 66 No Question Categories Skip pattern Instructions B403a What days of the week is the FP clinic open? (Tick all that apply) Monday ___ Tuesday ___ Wednesday ___ Thursday ___ Friday ___ Others, specify __________________ B403b What are the operating hours of the FP clinic? ____ : ____ to ____ : ____ U

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