Primary Healthcare Services Increase with Integration of Basic HIV Care, FHI Study Shows

MAY 2007—A new FHI study contributes hard data and empirical analysis to the important debate on how the scaling up of HIV clinical services has affected delivery of primary healthcare services. It found that integration of HIV clinical services in 30 primary health centers in Rwanda contributed to increased service delivery in general, and served as building blocks for strengthening and reinvigorating primary healthcare.

Sites Sampled

The low-cost, small-scale study was undertaken at the initiative of FHI staff in Rwanda. It examined data from 30 primary health centers, 21 operated by faith-based organizations and 9 by the Ministry of Health.

To facilitate data collection, sites studied were FHI partners that each had at least six months' experience offering basic HIV care, including counseling and testing, prevention of mother-to-child transmission of HIV (PMTCT), and preventive administration of cotrimoxazole. The quantity of non-HIV primary healthcare services delivered before and after the introduction of basic HIV care at each facility was compared by using data from monthly activity reports that each center submits to the National Health Information System.

Taken together, the 30 sites averaged nearly 32 months of mutuelle experience (Rwanda's primary health insurance system), nearly seven months of performance-based financing (funds tied to indicators for quantity and quality of services delivered), and about 16 months experience in basic HIV care. A regression analysis was conducted to evaluate any correlation between these factors and increased service delivery.

Methodology

The study collected aggregate monthly data on 88 health service delivery indicators for two time periods. The first period was six months prior to the first client testing for HIV at a given health center, and the second was December 2005 through May 2006. By the end of the second period, each site had at least six months' experience in offering basic HIV care. For each period, the mean quantities of non-HIV primary services delivered were calculated and data were compared and tested for significant differences.

Results

The study revealed 21 service delivery increases for the 30 centers after HIV care was introduced, of which 17 were statistically significant. The following areas registered the greatest increases:

• outpatient consultations (from 943 to 1,1743)
• non-HIV lab tests (from 545 to 645)
• syphilis screening of pregnant women (from 1 to 79)
• family planning (from 100 to 155 users, including an increase from 91 to 141 for returning users)
• child growth monitoring (from 760 to 1,038)

The number of women attending first- and second-trimester antenatal care visits also grew, along with the number who completed all four recommended visits. A subset of the data revealed that more than 80 percent of HIV-positive women enrolled in PMTCT programs returned to the health facilities to give birth. This is in sharp contrast with demographic health survey findings that less than 30 percent of Rwandan women give birth in health facilities.

Seven statistically significant service delivery increases were shown to be closely linked to the introduction of HIV care. No single factor could account for five increases, mutuelle experience accounted for four, and performance-based financing was associated with one service delivery increase.

This means that the introduction of basic HIV care did not damage the health system or have adverse effects of users of primary care services in the 30 centers. On the contrary, the introduction of basic HIV care contributed to increases in the delivery of general health care services and was associated with increases in the delivery of reproductive health services.

FHI's Approach

FHI's approach to integrating HIV care may have something to do with the increases noted in client uptake. FHI not only addresses technical areas of HIV care, but also ensures adequate infrastructure and builds organizational capacity in the areas of financial management, leadership, and human resources. These improvements are good for health services as a whole. "Simple upgrades, such as paint, tile, beds, and new curtains, make a world of difference," says FHI Country Director Jessica Price, who led the study. "All women are benefiting from the improved conditions."

Mukoma Health Center before renovation, October 2006	Mukoma Health Center after renovation, March 2007

Next Steps

Though limited in scope, the thought-provoking study contributes needed hard data to the debate on HIV spending and its impact on primary healthcare. Future studies may address factors such as the effect of integrating HIV services into STI, tuberculosis, and malaria services; whether improvements are being seen in the quality of non-HIV patient care; the specific costs of introducing HIV services; and improvements over time. A well-funded, rigorous, and more extensive study would help health programmers and government officials better allocate funds to maximize program impact on primary healthcare and use tax dollars more efficiently and effectively to improve a range of health services.

PHOTOS: (home page, and top) An ART provider with a patient in Kabgayi, Rwanda, circa 2003;  (above) Mukoma Health Clinic before and after renovations. Facilities are more inviting for patients and health care professionals alike after basic renovations.

— Clare Hayden