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Do Integrated Services Reduce Quality of Care?

Do Integrated Services Reduce Quality of Care?. James Kimani Charlotte Warren Population Council Richard Mutemwa Susannah Mayhew London School of Hygiene and Tropical Medicine. Findings from Kenya and Swaziland. Technical Approach for Assessing QOC.

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Do Integrated Services Reduce Quality of Care?

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  1. Do Integrated Services Reduce Quality of Care? • James Kimani • Charlotte Warren • Population Council • Richard Mutemwa • Susannah Mayhew • London School of Hygiene and Tropical Medicine Findings from Kenya and Swaziland

  2. Technical Approach for Assessing QOC • Underpinning assumption: integration improves quality of care (QoC) • Conceptual consideration for assessing QoC: • Structure- attributes of health care setting- infrastructure /supplies/trained personnel • Process- actual care delivered: • technical quality -entry point for integration effect; • interpersonal relations- client’s understanding of service provided/positive interaction with clients • Outcome – interaction of health care system with users- waiting time, satisfaction, client understanding of services • Analytical assessment for QoC: • Modified Grading model-based on a pre-defined criteria system

  3. Conceptual Framework for QoC Assessment Structure data Source: facility inventory and provider knowledge Process data Source: Client Provider Interviews Outcome Data source: exit interview • Waiting time • Before seeing provider/time with provider • Client understanding • Client Choice • Knowledge • Uptake of • PNC services • Satisfaction • Confidentiality/privacy • Continuity of care/follow up • Increase service provision • Range of services • Multiple service use • Diversification of client profile • Facility Inputs • Availability of appropriate services • Facility readiness: • Emergency preparedness • Equipment, medicines & supplies • Infection prevention • Infrastructure • Technical competence • Education and Training • Provider knowledge • Technical skills • History taking • Physical examination • Information given to client • Range of services offered: Family planning, HIV, STI Maternal health, Infant health • Documentation • Interpersonal care • Rapport • Client understanding Analysis of four rounds of health facility assessment data using composite quality scores Adapted from Donebedian (1966) and Bruce/Jain framework (1989)

  4. FP Services

  5. Factors Associated with Technical Quality of FP Services?

  6. Association between Integration and Technical Quality * p= 0.32 ** p = 0.89 *** p = 0.01 • A unit increase in integration (on the index) is associated with a 0.56 increase in technical quality of client-provider consultation sessions (on the technical quality score) – holding ‘treatment group’ constant and before controlling for structural factors

  7. Facility-level Structural Factors Associated with Technical Quality * p<0.05 ** p<0.001 §p>0.1

  8. PNC Services

  9. Grouped Indicators: Structure and Outcome

  10. Grouped Indicators: Process

  11. Structural Attributes of Care (0-119) Intervention

  12. Kenya: Quality of Postnatal Care Composite Scores (range 0-57) - Process

  13. Swaziland: Quality of Postnatal Care Composite Scores (0-57) - Process

  14. Client Satisfaction with PNC Services –Kenya & Swaziland *p<0.05

  15. Experiences of Health Care Providers with Integrated HIV and Reproductive Health Services • Benefits of integration as reported by providers • Increased client satisfaction • Professional stimulation • Experiential learning • Improved communication among staff • Increase in client repeat visits • Increase in service uptake • No more multiple queues per visit for the client • Increase in willingness to take HIV test among clients • Decrease in numbers of clients who leave before being attended during a visit

  16. Increased client satisfaction I think with integration, you are able to serve the client better and capture each and every detail of a patient (holistically). (The client) will not go home with a certain problem unattended. That is very satisfying. (Enrolled Nurse, Health Centre, Kitui) Clients come praising you, when you meet them outside (the facility). They say that your health service has really improved because you do not keep on sending us here and there causing stigma. (Enrolled Nurse, Hospital, Thika)

  17. Enhance provider skills through training I am more competent in the way I offer my services, I have the knowledge in every method, I have the knowledge to administer methods like the IUCD and jadelle which I never knew before, I have been able to treat people under one roof without referring them. (Enrolled Nurse, Sub-District Hospital, Thika) …because I'm able to see more clients than I used to and get more experience…because I'm dealing with different clients with different issues…it is building me as a nurse, profession-wise. So I'm more satisfied. (Registered Nurse, Sub-District Hospital, Kitui)

  18. Challenges of integration as reported by providers • Infrastructural and logistic deficiencies (insufficient physical room space, equipment, drugs and other medical supplies) • Long session times • Increased waiting times • Increased workload • Burdensome clinical recording • Lack of psychosocial support for occupational stress management • Low salaries • Low staffing levels

  19. Quality of Care – Key Messages • There is strong evidence that Integration of HIV into FP and HIV into PNC services can improve the quality of client-provider consultation sessions. • Overall, integration does not have a negative effect on quality of care. Generally, the higher the degree of integration the better the quality; HOWEVER, this has to be carefully balanced with risk of exacerbating some of the challenges discussed earlier, e.g. occupational stress, workload, waiting times. • Quality of care is complex: while some elements may be determined by the provider, many are determined by public health policy beyond the facility. Successful integration requires a health system-wide commitmentat both planning and implementation levels.

  20. Acknowledgements:Bill and Melinda Gates FoundationHard work of the entire Integra team: IPPF: Mathias Chatuluka; Taghreed El-Hajj; Phelele Fakudze; Jon Hopkins; Sheena Kakar; Irene Kamanga; Esther Kiragu; Lungile Mabuza; Agnes Makau; Edward Marienga; Zelda Nhlabatsi; Grace Neburagho; Stephen Njoka; Kevin Osborne; Lawrence Oteba; Lucy Stackpool-Moore; Ale Trossero; Muthoni Wachira. London School of Hygiene & Tropical Medicine: Linda Amarfio; Isolde Birdthistle; Kathryn Church; Manuela Colombini; Justin Fenty; Natalie Friend du Preeze; Joshua Kikuvi; Joelle Mak; Fiona Marquet; Susannah Mayhew; Christine Michaels-Igbokwe; Richard Mutemwa; Dayo Obure; George Ploubidis; Sedona Sweeney; Fern Terris-Prestholt; Keith Tomlin; Anna Vassall; Charlotte Watts; Weiwei Zhou. Population Council: Timothy Abuya; Ian Askew; Lucy Kanya; James Kimani; Jackie Kivunaga; Brian Mdawida; Charity Ndwiga; and Charlotte E Warren. Ministries of Health in Kenya, Malawi and Swaziland

  21. Thank youwww.integrainitiative.org

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