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Integration of HIV and maternal healthcare in a high HIV-prevalence setting: analysis of client flow data over time in Swaziland

Objective Maternal and child health (MCH) care may provide an entry point for HIV services in high HIV-prevalence settings. Our objective was to assess integration of HIV with MCH services in public sector facilities in Swaziland. Design In 2009, 2010 and 2012, client flow assessments (CFAs) were conducted over 5 days in the MCH units of eight government facilities, purposively selected as intervention or comparison sites. Participants 8263 MCH visits with female clients were tracked: 3261 in 2009, 2086 in 2010 and 2916 in 2012. Intervention Activities and resources to strengthen integration of HIV services into postnatal care (PNC), 2009–2010. Main outcome measures The proportion of all visits in which an HIV/sexually transmitted infection (STI) testing, counselling or treatment was received together with an MCH service; the proportion of all visits in which a client receives HIV counselling. Results Across facilities, the proportion of visits in which HIV/STI and MCH services were received varied considerably, for example, from 9% to 49% in 2009. HIV/STI services were integrated most frequently with child health (CH), antenatal care (ANC) and family planning (FP)—the most common reasons for women's attendance—and least often with PNC and cervical screening (CS). There was no meaningful difference in integration over time by design group and considerable heterogeneity across facilities. Receipt of integrated services increased in one intervention and two comparison facilities, where HIV counselling also rose, and fell in one intervention and two comparison facilities. Conclusions Provision of HIV/STI services with MCH care occurred at all facilities, yet relatively few women receive integrated services. Increases in integration were driven by increases in HIV counselling, while sharp declines in some facilities indicate that integration is difficult to sustain. Opportunities for intensifying HIV integration lie with ANC, CH and FP, while HIV-PNC integration will remain limited until more women attend PNC. Trial registration number Current Controlled Trials NCT01694862.

There was no evidence of an increase in integration in three of four intervention facilities. Impact of the intervention to strengthen integration of HIV into PNC will remain limited until more women attend PNC; the best opportunities for scaling up HIV integration may lie with ANC, child health and family planning, given their frequent use.

Strengths and limitations of this study
The main strength is the scale and novelty of client flow data in public sector facilities in sub-Saharan Africa, offering detailed combinations of services received in every consultation. Such detail is typically unavailable from routine health information systems.
An important limitation is the logistical challenge in conducting client flow assessments simultaneously across eight government facilities, affecting comparability of data across facilities and time points.

INTRODUCTION
Maternal mortality and HIV have been described as "intersecting epidemics" which must be simultaneously tackled. 1, 2 In the setting for this study -Swaziland, where more than 40% of pregnant women are infected with HIV -HIV is intimately linked with maternal mortality and hindering efforts to lower maternal death rates. 3,4 Since the International Conference on Population and Development in 1994, a strong case has been made for integrating HIV into sexual and reproductive health (SRH) with potential benefits for both clients and facilities. 5,6 Integration can simultaneously address clients' reproductive health goals and their needs for HIV prevention and treatment and PMTCT. 7 Process evaluations of integrated HIV and family planning (FP) services indicate that facilities can gain by increasing the provision, uptake and efficiency of services while improving client satisfaction and reducing HIV-related stigma in clinics. 8 More recently, the case for expanding integration of HIV/AIDS services to maternal, neonatal, child health and nutrition, including family planning, is supported in a systematic review which concludes that integration of such services is feasible to implement. 9 Furthermore, such integration can yield positive effects on the quality of services as well as client outcomes including contraceptive use, antiretroviral therapy in pregnancy, and HIV testing. 9 Maternal and child health services can thus serve as entry points for HIV prevention, treatment and care, particularly in contexts of high HIV prevalence. Yet little is known about existing

Data analysis
We defined our unit of analysis to be a visit, which comprised all providers seen and services received in the same day for each client, as captured on the client assessment form. Clients were either a single adult or an adult plus a child. We excluded visits of males aged 12 years or over, to focus on maternal and child health services. The age of 12 was selected as reproductive health services were received by females as young as 12.
The following primary and secondary outcomes were calculated for each facility and time point: 1. Receipt of integrated HIV-MCH services: the proportion of all visits in which a client receives any HIV or STI service, specifically: HIV testing, counselling or treatment; PMTCT; or STI counselling or testing and any of the following MCH services: FP counselling or provision; PNC for mother or baby; cervical cancer screening; child health (including weighing and immunisations); and antenatal care (ANC).
We hypothesised that HIV-MCH integration would increase in facilities which received the Integra intervention.  We also sought to describe which MCH services were most commonly combined with HIV/STI services, by calculating the percentage of visits in which an HIV/STI service was combined with each type of MCH service. We examined the change over time in the proportion of visits receiving integrated HIV/STI and MCH services (primary outcome) and HIV counselling (secondary outcome) separately for each facility. We used the 95% confidence interval around the difference (in the 2010 and 2012 proportions compared to 2009) as an indication of whether the observed change was due to chance (if it included the null value of zero).
To examine differences in the key outcomes by design group, we calculated the risk difference in 2010 and 2012 (each compared to 2009) for intervention versus comparison facilities for both the primary and secondary outcomes using a two-stage approach. In the first stage we estimated facility-level residuals by fitting a logistic regression model and including terms to adjust for baseline value (corresponding proportion of visits in 2009), average annual client load (<10000, 10000+), and rural/urban status. Difference residuals were then obtained as the difference between the observed and predicted values (divided by facility size). In the second stage we analysed the facility-level residuals, based on the assumption that in the absence of any intervention effect the residuals should be distributed normally with no systematic difference between the intervention and comparison arms. Difference residuals were analysed using linear regression including an interaction term representing the difference in 'change from baseline' between the design groups.

Receipt of integrated HIV-MCH services
There was evidence of HIV-MCH integration at all facilities and time points, although the extent of integration (the proportion of visits in which integrated HIV-MCH services were received) varied by facility: specifically, between 9% and 49% in 2009, 2%-22% in 2010 and 10-44% in 2012 (see Table 2). In the short-term, five facilities experienced declines in integration

Combinations of HIV/STI and MCH services received
In 2009, at least one client in every facility received each type of HIV-MCH integration investigated; that is, one or more clients received integration of HIV-FP (provision and counselling), HIV-ANC, HIV-PNC (for mother or baby), HIV-cervical screening (HIV-CS), and HIV-child health (HIV-CH). Figure 1 shows the proportion of visits in which each service combination was received at each facility. The most common integration in 2009 was HIV with child health services (up to 33% of all visits in Facility G), followed by HIV-ANC and HIV-FP (counselling or provision). Less frequent was integration of HIV services with PNC (a maximum of 6% of visits in Facility C) or cervical screening (maximum 6% of visits in Facility D).
In 2010, integration of HIV services with the MCH services no longer occurred in every facility.  The absolute numbers of visits that included HIV counselling are presented in Figure 2, which also shows that HIV counselling was more often provided in combination with an MCH service than alone. Specifically, HIV counselling was most often provided together with ANC, FP counselling or child health services (data not shown).

Evidence of an intervention effect
As shown in Table 2

DISCUSSION
With what we believe are among the most detailed data on HIV-MCH integration in the public sector in Africa, we have been able to assess the extent to which clients are receiving integrated services, and in which combinations over time. The client flow assessments have shown that HIV/STI services (counselling, testing and treatment) are being integrated with a wide range of MCH services, including family planning, ante-natal care, post-natal care, cervical screening and child health services. This is evidence of the capacity to integrate, in large urban facilities as well as small, rural facilities across Swaziland. It also fills a current gap in evidence -regarding the feasibility of integrating HIV services with infant/child health services, and postnatal/postpartum services. A recent systematic review of integration evaluations identified both models as 'inadequately studied' to date. 9 Nevertheless, integration occurred in a minority of visits and varied considerably across It is also possible that integration declined in settings where clients did not need HIV services with every visit. The CFA did not capture clients' history or need for such services, and thus we cannot interpret observed changes in their provision. For this reason we were particularly interested in the provision of HIV counselling, which can be promoted regardless of need for testing or treatment. HIV counselling rose in two intervention and two comparison facilities. In the three sites where HIV-MCH integration rose, this appeared to be driven by an increase in HIV counselling. That HIV counselling was most often provided with an MCH service rather than alone suggests it has an important role to play in scaling up integration, but requires a concerted effort to sustain its provision.
The most common form of integration observed was between HIV services and child health, followed by ANC and FP. These services may offer the best opportunities for integration with HIV, given most women attended for child health, ANC and FP services. This is particularly encouraging in light of a recent review concluding that uptake of PMTCT in sub-Saharan Africa is inadequate, but improves with an integrated family-centred approach, for example, if HIV treatment is provided at antenatal clinics. 7 Less common was integration of HIV/STI with PNC or cervical screening, most likely due to the lower number of clients receiving PNC and cervical screening relative to other services (or PNC clients may have received HIV/STI testing in recent ANC visits). This suggests that effectiveness of the Integra Initiative -which focuses on HIV-PNC integration in Swazilandmay be limited until more clients attend for PNC services. And this may require further investment in equipment and training for PNC (as well as cervical screening, as only one facility had the capacity to offer immediate cryotherapy) as well as demand creation to increase service uptake.
The formal comparison of integration by study design (intervention versus comparison sites) showed no statistical difference in HIV-MCH integration over time. Neither was there a meaningful difference in the receipt of HIV counselling in the intervention group over time.

Limitations and the challenges of embedding research in 'real-world' settings
The observed changes in levels of integration, and absence of an intervention effect, could be due to a number of factors which we were unable to account for given the non-randomised design, as well as challenges implementing the protocol as intended.
With regard to design: in a small country with limited number of facilities, intervention sites could not be matched with similar-sized comparison facilities without risk of contamination.
This resulted in systematically different groups, with intervention facilities primarily large and urban, and comparison facilities mostly small and rural. Given the resulting heterogeneity, we felt it was more informative to compare changes by facility than study design. The wide variation we observed across facilities likely reflects the different capacities and infrastructure available to provide integrated services, i.e., facilities can not follow the same 'blue print' for integration.
Some observed changes may also be due to 'seasonal' differences in 2009 and 2010. For  facilities -where the drops in integration were the steepest -may be impacted more than large, rural sites during such holiday periods.
It is also possible that provision of HIV and MCH services may fluctuate frequently or periodically, in patterns we could not detect from 5-day 'snapshot' assessments (regardless of their specific timing). It may be more informative to monitor over a longer period, for more representative data. Yet, the 5-day assessments proved challenging and resource-intensive to implement, and longer versions may be prohibitive in many settings. Strengthening routine data collection systems may be preferable, but many existing systems record services individually in separate registers, and are thus unable to document service integration without fundamentally changing the system. It was this barrier that led us to develop the client flow assessment.

Intervention
Activities and resources to strengthen integration of HIV services into post-natal care, 2009 -2010.

Main outcome measures
(1) The proportion of all visits in which an HIV/STI testing, counselling or treatment was received together with an MCH service; (2) The proportion of all visits in which a client receives HIV counselling.

Results
Across facilities, the proportion of visits in which both HIV/STI and MCH services were received varied considerably, e.g., from 9%-49% in 2009. HIV/STI services were integrated most frequently with child health, ante-natal care (ANC) and family planning -the most common reasons for women's attendance -and least often with post-natal care (PNC) and cervical screening. There was no meaningful difference in integration over time by design group, and considerable heterogeneity across facilities. Receipt of integrated services increased in one intervention and two comparison facilities, where HIV counseling also rose, and fell in one intervention and two comparison facilities.

Conclusions
Provision of HIV/STI services with MCH care occurred at all facilities, yet relatively few women receive integrated services. Increases in integration were driven by increases in HIV counseling while sharp declines in some facilities indicate integration is difficult to sustain. Opportunities for intensifying HIV integration lie with ANC, child health and family planning, while HIV-PNC integration will remain limited until more women attend PNC.

Key messages
Some provision of HIV/STI services with MCH care occurred at all facilities, indicating a capacity to integrate services in the public sector, yet relatively few women receive integrated services.
In three facilities, increases in integration over time were driven by increases in HIV counselling. Sharp declines in other facilities suggest integration is difficult to sustain, given frequent staff rotation and vertical HIV treatment campaigns that can divert resources for integration.

Strengths and limitations of this study
The main strength is the scale and novelty of client flow data in public sector facilities in sub-Saharan Africa, offering detailed combinations of services received in every consultation. Such detail is typically unavailable from routine health information systems.
An important limitation is the logistical challenge in conducting client flow assessments simultaneously across eight government facilities, affecting comparability of data across facilities and time points.

Page 5 of 52
For peer review only -http://bmjopen.bmj.com/site/about/guidelines.xhtml 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y  INTRODUCTION Maternal mortality and HIV have been described as "intersecting epidemics" which must be simultaneously tackled. 1, 2 In the setting for this study -Swaziland, where more than 40% of pregnant women are infected with HIV -HIV is intimately linked with maternal mortality and hinders efforts to lower maternal death rates. 3,4 Since the International Conference on Population and Development in 1994, a strong case has been made for integrating HIV services into sexual and reproductive health (SRH) with potential benefits for both clients and facilities. 5,6 Integration can simultaneously address clients' reproductive health goals and their needs for HIV prevention and treatment and PMTCT. 7 Process evaluations of integrated HIV and family planning (FP) services indicate that facilities can gain by increasing the provision, uptake and efficiency of services while improving client satisfaction and reducing HIV-related stigma in clinics. 8 More recently, the case for expanding integration of HIV/AIDS services to maternal, neonatal, child health and nutrition, including family planning, is supported in a systematic review which concludes that integration of such services is feasible to implement under certain circumstances. 9 Furthermore, such integration can yield positive effects on the quality of services as well as client outcomes including contraceptive use, antiretroviral therapy in pregnancy, and HIV testing. 9 Maternal and child health services can thus serve as entry points for HIV prevention, treatment and care, particularly in contexts of high HIV prevalence. Yet little is known about existing   10 We also sought to understand how the receipt of integrated services differs over time and between facilities which did and did not receive the Integra intervention. We hoped the answers would help identify gaps and opportunities for integrating HIV within maternal health services and achieving universal access to both.

Data Collection
As part of Integra's non-randomised design, eight public sector facilities were selected from three of Swaziland's four regions. Four facilities were purposively designated as Intervention facilities (referred to as Facilities A-D), based on their previous participation in an operations  The CFAs were modelled on the Patient Flow Analysis, a method developed by the Centers for Disease Control in the 1970s to track patients' movements through a clinic over one day, 13,14 and shown to be effective in measuring intervention effectiveness within the context of usual practice. 15 In this context, CFAs were designed to capture service utilisation patterns among clients seeking MCH services, given that data on integrated service provision were not available from routine clinical data (which collect data on different services in separate registers

Data analysis
We defined our unit of analysis to be a visit, which comprised all providers seen and services received in the same day for each client, as captured on the client assessment form. Clients were either a single adult or an adult plus a child. We excluded visits of males aged 12 years or over, to focus on maternal and child health services. The age of 12 was selected as reproductive health services were received by females as young as 12.
The following primary and secondary outcomes were calculated for each facility and time point: 1. Receipt of integrated HIV-MCH services: the proportion of all visits in which a client receives any HIV or STI service, specifically: HIV testing, counselling or treatment; PMTCT; or STI counselling or testing  We hypothesised that HIV counselling would increase as a result of the Integra intervention, regardless of women's need for HIV testing or treatment which are not constant (medical histories, including the need for testing or treatment, were not captured on the CFA form).
We also sought to describe which MCH services were most commonly combined with HIV/STI services, by calculating the percentage of visits in which an HIV/STI service was combined with each type of MCH service. We examined the change over time in the proportion of visits receiving integrated HIV/STI and MCH services (primary outcome) and HIV counselling (secondary outcome) separately for each facility. We used the 95% confidence interval around the difference (in the 2010 and 2012 proportions compared to 2009) as an indication of whether the observed change was due to chance (if it included the null value of zero).
To examine differences in the key outcomes by design group, we calculated the risk difference in 2010 and 2012 (each compared to 2009) for intervention versus comparison facilities for both the primary and secondary outcomes using a two-stage approach. In the first stage we  load (<10000, 10000+), and rural/urban status. Difference residuals were then obtained as the difference between the observed and predicted values (divided by facility size). In the second stage we analysed the facility-level residuals, based on the assumption that in the absence of any intervention effect the residuals should be distributed normally with no systematic difference between the intervention and comparison arms. Difference residuals were analysed using linear regression including an interaction term representing the difference in 'change from baseline' between the design groups.

Ethics Statement
Ethics approval for the client flow assessments was obtained from the Swaziland Scientific   service or referral during their visit, with the highest proportions in the facilities with highest client load (e.g., 18% of clients in Facility B and 31% in Facility D in 2010). In all facilities, and in both years, child health services were either the first or second most common service received.
Family planning counselling or provision, and ante-natal care, were among the top three services for most facilities. Across facilities, the least common services received were post-natal care and cervical screening (See Supplementary

Receipt of HIV counselling
As a secondary outcome, we hypothesised that HIV counselling would increase in the intervention facilities. Table 2 shows that the proportion of visits in which a client received HIV counselling increased between 2009 and 2012 in two intervention (A,D) and two comparison facilities (E,F), and declined in two intervention sites (Facility C) and two comparison sites (G,H).
The absolute numbers of visits that included HIV counselling are presented in Figure 2, which also shows that HIV counselling was more often provided in combination with an MCH service than alone. Specifically, HIV counselling was most often provided together with ANC, FP counselling or child health services (data not shown).

Evidence of an intervention effect
As shown in Table 2 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  It is also possible that integration declined in settings where clients did not need HIV services with every visit. The CFA did not capture clients' history or need for such services, and thus we  cannot interpret observed changes in their provision. For this reason we were particularly interested in the provision of HIV counselling, which can be promoted regardless of need for testing or treatment. HIV counselling rose in two intervention and two comparison facilities. In the three sites where HIV-MCH integration rose, this appeared to be driven by an increase in HIV counselling. That HIV counselling was most often provided with an MCH service rather than alone suggests it has arole to play in scaling up integration, but requires a concerted effort to sustain its provision.
The most common form of integration observed was between HIV services and child health, followed by ANC and FP. These services may offer the best opportunities for integration with HIV, given most women attended for child health, ANC and FP services. This is particularly encouraging in light of a recent review concluding that uptake of PMTCT in sub-Saharan Africa is inadequate, but improves with an integrated family-centred approach, for example, if HIV treatment is provided at antenatal clinics. 7 Less common was integration of HIV/STI with PNC or cervical screening, most likely due to the lower number of clients receiving PNC and cervical screening relative to other services (or PNC clients may have received HIV/STI testing in recent ANC visits). This suggests that potential effectiveness of the Integra Initiative -which focuses on HIV-PNC integration in Swaziland -may be limited until more clients attend for PNC services. And this may require further investment in equipment and training for PNC (as well as cervical screening, as only one facility had the capacity to offer immediate cryotherapy) as well as demand creation to increase service uptake.  The formal comparison of integration by study design (intervention versus comparison sites) showed no statistical difference in HIV-MCH integration over time. Neither was there a meaningful difference in the receipt of HIV counselling in the intervention group over time.

Limitations and the challenges of embedding research in 'real-world' settings
The observed changes in levels of integration, and absence of an intervention effect, could be due to a number of factors which we were unable to account for given the non-randomised design, as well as challenges implementing the protocol as intended.
With regard to design: in a small country with limited number of facilities, intervention sites could not be matched with similar-sized comparison facilities. This resulted in systematically different groups, with intervention facilities primarily large and urban, and comparison facilities mostly small and rural. Given the resulting heterogeneity, and the focus on a facility-specific outcome in this analysis, we felt it was more informative to compare changes by facility than study design. The wide variation we observed across facilities likely reflects the different capacities and infrastructure available to provide integrated services, i.e., facilities can not follow the same 'blue print' for integration, particularly given the variability in facility size, client volumes and staffing levels among the eight study facilities. Detailed case studies are underway to explore the role of facility differences in greater depth, including intervention dose and quality, as well as contextual information, to enhance interpretation of the levels and patterns of integration revealed by the client flow assessments.  It is also possible that provision of HIV and MCH services may fluctuate frequently or periodically, in patterns we could not detect from 5-day 'snapshot' assessments (regardless of their specific timing). An early evaluation of CDC's 'patient flow analysis' method, conducted over one day in family planning clinics in Kenya, concluded that: "the 'typical' clinic day does not really exist. The client/patient load and staffing patterns are likely to vary according to many factors: by day of the week, or season of the year, staff vacation or sickness, etc." 14 Assessments were extended to five days in this study, yet, neither does the 'typical' clinic week exist. It may be more informative to monitor over a longer period, for more representative data. However, the 5-day assessments proved challenging and resource-intensive to implement, and longer versions may be prohibitive in many settings. Previous evaluations of patient flow analyses also note that data may not be representative since staff -aware of the assessment -may try to perform at their best. 14 For these reasons, strengthening routine data collection systems may be preferable, but many existing systems record services individually in  separate registers, and are thus unable to document service integration without fundamentally changing the system. It was this barrier that led us to utilise the client flow assessment.

Acknowledgements
The authors are grateful to the clients and the Integra fieldwork team for collecting and managing the data used in this analysis. We also acknowledge the support of the Ministry of Health and facility managers and providers for supporting and facilitating the client flow assessments.

Author contributions
SM, JK, CW, KC, RN helped to design the data collection. JK managed the data collection. JF and WZ cleaned and managed the datasets. IB and JF led the analysis. All authors provided input into the data interpretation. IB drafted the manuscript. All authors read and commented on a complete draft.

Data sharing
The dataset will be made available via an LSHTM repository upon completion of the Integra Initiative.

Competing interests statement
The authors have declared that no competing interests exist.

Funding statement
This work was supported by the Bill and Melinda Gates Foundation. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Key messages
Some provision of HIV/STI services with MCH care occurred at all facilities, indicating a capacity to integrate services in the public sector, yet relatively few women receive integrated services.
In three facilities, increases in integration over time were driven by increases in HIV counselling. Sharp declines in other facilities suggest integration is difficult to sustain, given frequent staff rotation and vertical HIV treatment campaigns that can divert resources for integration.  There was no evidence of an increase in integration in three of four intervention facilities. Impact of the intervention to strengthen integration of HIV into PNC will remain limited until more women attend PNC; the best opportunities for scaling up HIV integration may lie with ANC, child health and family planning, given their frequent use.

Strengths and limitations of this study
The main strength is the scale and novelty of client flow data in public sector facilities in sub-Saharan Africa, offering detailed combinations of services received in every consultation. Such detail is typically unavailable from routine health information systems.
An important limitation is the logistical challenge in conducting client flow assessments simultaneously across eight government facilities, affecting comparability of data across facilities and time points.

INTRODUCTION
Maternal mortality and HIV have been described as "intersecting epidemics" which must be simultaneously tackled. 1, 2 In the setting for this study -Swaziland, where more than 40% of pregnant women are infected with HIV -HIV is intimately linked with maternal mortality and hindersing efforts to lower maternal death rates. 3,4 Since the International Conference on Population and Development in 1994, a strong case has been made for integrating HIV services into sexual and reproductive health (SRH) with potential benefits for both clients and facilities. 5,6 Integration can simultaneously address clients' reproductive health goals and their needs for HIV prevention and treatment and PMTCT. 7 Process evaluations of integrated HIV and family planning (FP) services indicate that facilities can gain by increasing the provision, uptake and efficiency of services while improving client satisfaction and reducing HIV-related stigma in clinics. 8 More recently, the case for expanding integration of HIV/AIDS services to maternal, neonatal, child health and nutrition, including family planning, is supported in a systematic review which concludes that integration of such services is feasible to implement under certain circumstances. 9 Furthermore, such integration can yield positive effects on the quality of services as well as client outcomes including contraceptive use, antiretroviral therapy in pregnancy, and HIV testing. 9 Maternal and child health services can thus serve as entry points for HIV prevention, treatment and care, particularly in contexts of high HIV prevalence. Yet little is known about existing  The Integra Initiative is a large-scale non-randomised evaluation was designed to assess evaluate different models of SRH-HIV integration, including the integration of HIV/STI services with post-natal care (PNC) in Swaziland. 10 Although not a randomised controlled trial, Integra was registered for good practice and transparency (Current Controlled Trials NCT01694862).
The specific models of integration -including the use of post-natal care as an entry point for HIV/STI services in Swaziland -and their hypothesised benefits for clients and health care efficiency are detailed in the Integra study protocol. 10 As part of the Integra Initiative, this study analysed client flow data collected in eight public sector facilities in Swaziland in 2009, 2010 and 2012, to determine whether clients seeking maternal and child health services (MCH) receive integrated services, and if so, in what combinations of HIV/STI and MCH services. 10 We also sought to understand how the receipt of integrated services differs over time and between facilities which did and did not receive the Integra intervention. We hoped the answers would help identify gaps and opportunities for integrating HIV within maternal health services and achieving universal access to both.

Data Collection
As part of Integra's non-randomised design, eight public sector facilities were selected from three of Swaziland's four regions. Four facilities were purposively designated as Intervention facilities (referred to as Facilities A-D), based on their previous participation in an operations  The CFAs were modelled on the Patient Flow Analysis, a method developed by the Centers for Disease Control in the 1970s to track patients' movements through a clinic over one day, 13,14 and shown to be effective in measuring intervention effectiveness within the context of usual practice. 15 and In this context, CFAs were designed to capture service utilisation patterns among clients seeking MCH services, given that data on integrated service provision were not available from routine clinical data (which collect data on different services in separate registers

Data analysis
We defined our unit of analysis to be a visit, which comprised all providers seen and services received in the same day for each client, as captured on the client assessment form. Clients were either a single adult or an adult plus a child. We excluded visits of males aged 12 years or over, to focus on maternal and child health services. The age of 12 was selected as reproductive health services were received by females as young as 12.
The following primary and secondary outcomes were calculated for each facility and time point: 1. Receipt of integrated HIV-MCH services: the proportion of all visits in which a client receives any HIV or STI service, specifically: HIV testing, counselling or treatment; PMTCT; or STI counselling or testing  We hypothesised that HIV counselling would increase as a result of the Integra intervention, regardless of women's need for HIV testing or treatment which are not constant (medical histories, including the need for testing or treatment, were not captured on the CFA form).
We also sought to describe which MCH services were most commonly combined with HIV/STI services, by calculating the percentage of visits in which an HIV/STI service was combined with each type of MCH service. We examined the change over time in the proportion of visits receiving integrated HIV/STI and MCH services (primary outcome) and HIV counselling (secondary outcome) separately for each facility. We used the 95% confidence interval around the difference (in the 2010 and 2012 proportions compared to 2009) as an indication of whether the observed change was due to chance (if it included the null value of zero).

Receipt of HIV counselling
As a secondary outcome, we hypothesised that HIV counselling would increase in the intervention facilities. Table 2 shows that the proportion of visits in which a client received HIV counselling increased between 2009 and 2012 in two intervention (A,D) and two comparison facilities (E,F), and declined in two intervention sites (Facility C) and two comparison sites (G,H).
The absolute numbers of visits that included HIV counselling are presented in Figure 2, which also shows that HIV counselling was more often provided in combination with an MCH service than alone. Specifically, HIV counselling was most often provided together with ANC, FP counselling or child health services (data not shown).

Evidence of an intervention effect
As shown in Table 2 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  It is also possible that integration declined in settings where clients did not need HIV services with every visit. The CFA did not capture clients' history or need for such services, and thus we  cannot interpret observed changes in their provision. For this reason we were particularly interested in the provision of HIV counselling, which can be promoted regardless of need for testing or treatment. HIV counselling rose in two intervention and two comparison facilities. In the three sites where HIV-MCH integration rose, this appeared to be driven by an increase in HIV counselling. That HIV counselling was most often provided with an MCH service rather than alone suggests it has an important role to play in scaling up integration, but requires a concerted effort to sustain its provision.
The most common form of integration observed was between HIV services and child health, followed by ANC and FP. These services may offer the best opportunities for integration with HIV, given most women attended for child health, ANC and FP services. This is particularly encouraging in light of a recent review concluding that uptake of PMTCT in sub-Saharan Africa is inadequate, but improves with an integrated family-centred approach, for example, if HIV treatment is provided at antenatal clinics. 7 Less common was integration of HIV/STI with PNC or cervical screening, most likely due to the lower number of clients receiving PNC and cervical screening relative to other services (or

PNC clients may have received HIV/STI testing in recent ANC visits). This suggests that potential effectiveness of the Integra Initiative -which focuses on HIV-PNC integration in
Swaziland -may be limited until more clients attend for PNC services. And this may require further investment in equipment and training for PNC (as well as cervical screening, as only one facility had the capacity to offer immediate cryotherapy) as well as demand creation to increase service uptake.  The formal comparison of integration by study design (intervention versus comparison sites) showed no statistical difference in HIV-MCH integration over time. Neither was there a meaningful difference in the receipt of HIV counselling in the intervention group over time.

Limitations and the challenges of embedding research in 'real-world' settings
The observed changes in levels of integration, and absence of an intervention effect, could be due to a number of factors which we were unable to account for given the non-randomised design, as well as challenges implementing the protocol as intended.
With regard to design: in a small country with limited number of facilities, intervention sites could not be matched with similar-sized comparison facilities without risk of contamination.
This resulted in systematically different groups, with intervention facilities primarily large and urban, and comparison facilities mostly small and rural. Given the resulting heterogeneity, and the focus on a facility-specific outcome in this analysis, we felt it was more informative to compare changes by facility than study design. The wide variation we observed across facilities likely reflects the different capacities and infrastructure available to provide integrated services, i.e., facilities can not follow the same 'blue print' for integration, particularly given the variability in facility size, client volumes and staffing levels among the eight study facilities.
Detailed case studies are underway to explore the role of facility differences in greater depth, including intervention dose and quality, as well as contextual information, to enhance interpretation of the levels and patterns of integration revealed by the client flow assessments.  It is also possible that provision of HIV and MCH services may fluctuate frequently or periodically, in patterns we could not detect from 5-day 'snapshot' assessments (regardless of their specific timing). An early evaluation of CDC's 'patient flow analysis' method, conducted over one day in family planning clinics in Kenya, concluded that: "the 'typical' clinic day does not really exist. The client/patient load and staffing patterns are likely to vary according to many factors: by day of the week, or season of the year, staff vacation or sickness, etc." 14 Assessments were extended to five days in this study, yet, neither does the 'typical' clinic week exist. It may be more informative to monitor over a longer period, for more representative data. YetHowever, the 5-day assessments proved challenging and resource-intensive to implement, and longer versions may be prohibitive in many settings. Previous evaluations of patient flow analyses also note that data may not be representative since staff -aware of the  assessment -may try to perform at their best. 14 For these reasons, Sstrengthening routine data collection systems may be preferable, but many existing systems record services individually in separate registers, and are thus unable to document service integration without fundamentally changing the system. It was this barrier that led us to develop utilise the client flow assessment.

Conclusions
The client flow assessment provided rich detail about the range and combinations of services

Acknowledgements
The authors are grateful to the clients and the Integra fieldwork team for collecting and managing the data used in this analysis. We also acknowledge the support of the Ministry of Health and facility managers and providers for supporting and facilitating the client flow assessments.

Author contributions
SM, JK, CW, KC, RN helped to design the data collection. JK managed the data collection. JF and WZ cleaned and managed the datasets. IB and JF led the analysis. All authors provided input into the data interpretation. IB drafted the manuscript. All authors read and commented on a complete draft.

Data sharing
The dataset will be made available via an LSHTM repository upon completion of the Integra Initiative.

Competing interests statement
The authors have declared that no competing interests exist.

F o r p e e r r e v i e w o n l y
Supplementary

Main outcome measures
(1) The proportion of all visits in which an HIV/STI testing, counselling or treatment was received together with an MCH service; (2) The proportion of all visits in which a client receives HIV counselling.    We also assessed whether these outcomes improved with time in facilities which received an intervention designed to strengthen integration of HIV into post-natal care services (the Integra Initiative).

Key messages
Some provision of HIV/STI services with MCH care occurred at all facilities, indicating a capacity to integrate services in the public sector, yet relatively few women receive integrated services.
In three facilities, increases in integration over time were driven by increases in HIV counselling. Sharp declines in other facilities suggest integration is difficult to sustain, given frequent staff rotation and vertical HIV treatment campaigns that can divert resources for integration.  There was no evidence of an increase in integration in three of four intervention facilities. Impact of the intervention to strengthen integration of HIV into PNC will remain limited until more women attend PNC; the best opportunities for scaling up HIV integration may lie with ANC, child health and family planning, given their frequent use.

Strengths and limitations of this study
The main strength is the scale and novelty of client flow data in public sector facilities in sub-Saharan Africa, offering detailed combinations of services received in every consultation. Such detail is typically unavailable from routine health information systems.
An important limitation is the logistical challenge in conducting client flow assessments simultaneously across eight government facilities, affecting comparability of data across facilities and time points.

INTRODUCTION
Maternal mortality and HIV have been described as "intersecting epidemics" which must be simultaneously tackled. 1, 2 In the setting for this study -Swaziland, where more than 40% of pregnant women are infected with HIV -HIV is intimately linked with maternal mortality and hinders efforts to lower maternal death rates. 3,4 Since the International Conference on Population and Development in 1994, a strong case has been made for integrating HIV services into sexual and reproductive health (SRH) with potential benefits for both clients and facilities. 5,6 Integration can simultaneously address clients' reproductive health goals and their needs for HIV prevention and treatment and PMTCT. 7 Process evaluations of integrated HIV and family planning (FP) services indicate that facilities can gain by increasing the provision, uptake and efficiency of services while improving client satisfaction and reducing HIV-related stigma in clinics. 8 More recently, the case for expanding integration of HIV/AIDS services to maternal, neonatal, child health and nutrition, including family planning, is supported in a systematic review which concludes that integration of such services is feasible to implement under certain circumstances. 9 Furthermore, such integration can yield positive effects on the quality of services as well as client outcomes including contraceptive use, antiretroviral therapy in pregnancy, and HIV testing. 9 Maternal and child health services can thus serve as entry points for HIV prevention, treatment and care, particularly in contexts of high HIV prevalence. Yet little is known about existing   10 We also sought to understand how the receipt of integrated services differs over time and between facilities which did and did not receive the Integra intervention. We hoped the answers would help identify gaps and opportunities for integrating HIV within maternal health services and achieving universal access to both.

Data Collection
As part of Integra's non-randomised design, eight public sector facilities were selected from three of Swaziland's four regions. Four facilities were purposively designated as Intervention  The CFAs were modelled on the Patient Flow Analysis, a method developed by the Centers for Disease Control in the 1970s to track patients' movements through a clinic over one day, 13,14 and shown to be effective in measuring intervention effectiveness within the context of usual practice. 15 In this context, CFAs were designed to capture service utilisation patterns among clients seeking MCH services, given that data on integrated service provision were not available from routine clinical data (which collect data on different services in separate

Data analysis
We defined our unit of analysis to be a visit, which comprised all providers seen and services received in the same day for each client, as captured on the client assessment form. Clients were either a single adult or an adult plus a child. We excluded visits of males aged 12 years or over, to focus on maternal and child health services. The age of 12 was selected as reproductive health services were received by females as young as 12.  We hypothesised that HIV counselling would increase as a result of the Integra intervention, regardless of women's need for HIV testing or treatment which are not constant (medical histories, including the need for testing or treatment, were not captured on the CFA form).
We also sought to describe which MCH services were most commonly combined with HIV/STI services, by calculating the percentage of visits in which an HIV/STI service was combined with each type of MCH service. We examined the change over time in the proportion of visits receiving integrated HIV/STI and MCH services (primary outcome) and HIV counselling

Ethics Statement
Ethics approval for the client flow assessments was obtained from the Swaziland Scientific

Review Board, the London School of Hygiene & Tropical Medicine and the Population Council
Institutional Review Board.

Receipt of HIV counselling
As a secondary outcome, we hypothesised that HIV counselling would increase in the intervention facilities. Table 2 shows that the proportion of visits in which a client received HIV counselling increased between 2009 and 2012 in two intervention (A,D) and two comparison facilities (E,F), and declined in two intervention sites (Facility C) and two comparison sites (G,H).
The absolute numbers of visits that included HIV counselling are presented in Figure 2, which also shows that HIV counselling was more often provided in combination with an MCH service than alone. Specifically, HIV counselling was most often provided together with ANC, FP counselling or child health services (data not shown).
The most common form of integration observed was between HIV services and child health, followed by ANC and FP. These services may offer the best opportunities for integration with HIV, given most women attended for child health, ANC and FP services. This is particularly encouraging in light of a recent review concluding that uptake of PMTCT in sub-Saharan Africa is inadequate, but improves with an integrated family-centred approach, for example, if HIV treatment is provided at antenatal clinics. 7 Less common was integration of HIV/STI with PNC or cervical screening, most likely due to the lower number of clients receiving PNC and cervical screening relative to other services (or PNC clients may have received HIV/STI testing in recent ANC visits). This suggests that potential effectiveness of the Integra Initiative -which focuses on HIV-PNC integration in Swaziland -may be limited until more clients attend for PNC services. And this may require further investment in equipment and training for PNC (as well as cervical screening, as only one facility had the capacity to offer immediate cryotherapy) as well as demand creation to increase service uptake.

Limitations and the challenges of embedding research in 'real-world' settings
The observed changes in levels of integration, and absence of an intervention effect, could be due to a number of factors which we were unable to account for given the non-randomised design, as well as challenges implementing the protocol as intended.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  It is also possible that provision of HIV and MCH services may fluctuate frequently or periodically, in patterns we could not detect from 5-day 'snapshot' assessments (regardless of their specific timing). An early evaluation of CDC's 'patient flow analysis' method, conducted over one day in family planning clinics in Kenya, concluded that: "the 'typical' clinic day does not really exist. The client/patient load and staffing patterns are likely to vary according to many factors: by day of the week, or season of the year, staff vacation or sickness, etc." 14 Assessments were extended to five days in this study, yet, neither does the 'typical' clinic week exist. It may be more informative to monitor over a longer period, for more representative data. However, the 5-day assessments proved challenging and resource-intensive to implement, and longer versions may be prohibitive in many settings. Previous evaluations of patient flow analyses also note that data may not be representative since staff -aware of the  assessment -may try to perform at their best. 14 For these reasons, strengthening routine data collection systems may be preferable, but many existing systems record services individually in separate registers, and are thus unable to document service integration without fundamentally changing the system. It was this barrier that led us to utilise the client flow assessment.

Conclusions
The

Key messages
Some provision of HIV/STI services with MCH care occurred at all facilities, indicating a capacity to integrate services in the public sector, yet relatively few women receive integrated services.
In three facilities, increases in integration over time were driven by increases in HIV counselling. Sharp declines in other facilities suggest integration is difficult to sustain, given frequent staff rotation and vertical HIV treatment campaigns that can divert resources for integration.  There was no evidence of an increase in integration in three of four intervention facilities. Impact of the intervention to strengthen integration of HIV into PNC will remain limited until more women attend PNC; the best opportunities for scaling up HIV integration may lie with ANC, child health and family planning, given their frequent use.

INTRODUCTION
Maternal mortality and HIV have been described as "intersecting epidemics" which must be simultaneously tackled. 1, 2 In the setting for this study -Swaziland, where more than 40% of pregnant women are infected with HIV -HIV is intimately linked with maternal mortality and hinders efforts to lower maternal death rates. 3,4 Since the International Conference on Population and Development in 1994, a strong case has been made for integrating HIV services into sexual and reproductive health (SRH) with potential benefits for both clients and facilities. 5,6 Integration can simultaneously address clients' reproductive health goals and their needs for HIV prevention and treatment and PMTCT. 7 Process evaluations of integrated HIV and family planning (FP) services indicate that facilities can gain by increasing the provision, uptake and efficiency of services while improving client satisfaction and reducing HIV-related stigma in clinics. 8 More recently, the case for expanding integration of HIV/AIDS services to maternal, neonatal, child health and nutrition, including family planning, is supported in a systematic review which concludes that integration of such services is feasible to implement under certain circumstances. 9 Furthermore, such integration can yield positive effects on the quality of services as well as client outcomes including contraceptive use, antiretroviral therapy in pregnancy, and HIV testing. 9 Maternal and child health services can thus serve as entry points for HIV prevention, treatment and care, particularly in contexts of high HIV prevalence. Yet little is known about existing   10 We also sought to understand how the receipt of integrated services differs over time and between facilities which did and did not receive the Integra intervention. We hoped the answers would help identify gaps and opportunities for integrating HIV within maternal health services and achieving universal access to both.  The CFAs were modelled on the Patient Flow Analysis, a method developed by the Centers for Disease Control in the 1970s to track patients' movements through a clinic over one day, 13,14 and shown to be effective in measuring intervention effectiveness within the context of usual practice. 15 In this context, CFAs were designed to capture service utilisation patterns among  sites, as the protocol had intended. In some facilities, with the support of facility managers, client flow assessments were conducted for more than the five days intended. To preserve the original protocol design, we restricted this analysis to the first Monday through Friday on which data were collected.

Data analysis
We defined our unit of analysis to be a visit, which comprised all providers seen and services received in the same day for each client, as captured on the client assessment form. Clients were either a single adult or an adult plus a child. We excluded visits of males aged 12 years or  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  over, to focus on maternal and child health services. The age of 12 was selected as reproductive health services were received by females as young as 12.
The following primary and secondary outcomes were calculated for each facility and time point: 1. Receipt of integrated HIV-MCH services: the proportion of all visits in which a client receives any HIV or STI service, specifically: HIV testing, counselling or treatment; PMTCT; or STI counselling or testing and any of the following MCH services: FP counselling or provision; PNC for mother or baby; cervical cancer screening; child health (including weighing and immunisations); and antenatal care (ANC).
We hypothesised that HIV-MCH integration would increase in facilities which received the Integra intervention. We hypothesised that HIV counselling would increase as a result of the Integra intervention, regardless of women's need for HIV testing or treatment which are not constant (medical histories, including the need for testing or treatment, were not captured on the CFA form).
We also sought to describe which MCH services were most commonly combined with HIV/STI services, by calculating the percentage of visits in which an HIV/STI service was combined with  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  To examine differences in the key outcomes by design group, we calculated the risk difference in 2010 and 2012 (each compared to 2009) for intervention versus comparison facilities for both the primary and secondary outcomes using a two-stage approach. In the first stage we estimated facility-level residuals by fitting a logistic regression model and including terms to adjust for baseline value (corresponding proportion of visits in 2009), average annual client load (<10000, 10000+), and rural/urban status. Difference residuals were then obtained as the difference between the observed and predicted values (divided by facility size). In the second stage we analysed the facility-level residuals, based on the assumption that in the absence of any intervention effect the residuals should be distributed normally with no systematic difference between the intervention and comparison arms. Difference residuals were analysed using linear regression including an interaction term representing the difference in 'change from baseline' between the design groups.

Receipt of HIV counselling
As a secondary outcome, we hypothesised that HIV counselling would increase in the intervention facilities. Table 2 shows that the proportion of visits in which a client received HIV counselling increased between 2009 and 2012 in two intervention (A,D) and two comparison facilities (E,F), and declined in two intervention sites (Facility C) and two comparison sites (G,H).
The absolute numbers of visits that included HIV counselling are presented in Figure 2, which also shows that HIV counselling was more often provided in combination with an MCH service than alone. Specifically, HIV counselling was most often provided together with ANC, FP counselling or child health services (data not shown).

Evidence of an intervention effect
As shown in Table 2 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  It is also possible that integration declined in settings where clients did not need HIV services with every visit. The CFA did not capture clients' history or need for such services, and thus we cannot interpret observed changes in their provision. For this reason we were particularly interested in the provision of HIV counselling, which can be promoted regardless of need for testing or treatment. HIV counselling rose in two intervention and two comparison facilities. In the three sites where HIV-MCH integration rose, this appeared to be driven by an increase in HIV counselling. That HIV counselling was most often provided with an MCH service rather than alone suggests it has arole to play in scaling up integration, but requires a concerted effort to sustain its provision.
The most common form of integration observed was between HIV services and child health, followed by ANC and FP. These services may offer the best opportunities for integration with HIV, given most women attended for child health, ANC and FP services. This is particularly encouraging in light of a recent review concluding that uptake of PMTCT in sub-Saharan Africa is inadequate, but improves with an integrated family-centred approach, for example, if HIV treatment is provided at antenatal clinics. 7 Less common was integration of HIV/STI with PNC or cervical screening, most likely due to the lower number of clients receiving PNC and cervical screening relative to other services (or PNC clients may have received HIV/STI testing in recent ANC visits). This suggests that potential effectiveness of the Integra Initiative -which focuses on HIV-PNC integration in Swaziland -may be limited until more clients attend for PNC services. And this may require further investment in equipment and training for PNC (as well as cervical screening, as only one facility had the capacity to offer immediate cryotherapy) as well as demand creation to increase service uptake.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  The formal comparison of integration by study design (intervention versus comparison sites) showed no statistical difference in HIV-MCH integration over time. Neither was there a meaningful difference in the receipt of HIV counselling in the intervention group over time.

Limitations and the challenges of embedding research in 'real-world' settings
The observed changes in levels of integration, and absence of an intervention effect, could be due to a number of factors which we were unable to account for given the non-randomised design, as well as challenges implementing the protocol as intended.
With regard to design: in a small country with limited number of facilities, intervention sites could not be matched with similar-sized comparison facilities. This resulted in systematically different groups, with intervention facilities primarily large and urban, and comparison facilities mostly small and rural. Also, the comparison sites -which were determined to have no provision of integration prior to the study in 2008 -were shown via the client flow assessments to be offering integrated HIV-RH services by 2009. Given the resulting heterogeneity, and the focus on a facility-specific outcome in this analysis, we felt it was more informative to compare changes by facility than study design. The wide variation we observed across facilities likely reflects the different capacities and infrastructure available to provide integrated services, i.e., facilities can not follow the same 'blue print' for integration, particularly given the variability in facility size, client volumes and staffing levels among the eight study facilities. Detailed case studies are underway to explore the role of facility differences in greater depth, including intervention dose and quality, as well as contextual information, to enhance interpretation of the levels and patterns of integration revealed by the client flow assessments.
Some observed changes may also be due to 'seasonal' differences in 2009 and 2010.
Coordinating client flow assessments across eight facilities proved logistically challenging and synchronicity was not always achieved as intended. In 2010, most assessments were delayed until the week before Christmas (as compared to November 2009) which may account for the smaller number of clients in most facilities in 2010. This timing may have affected the range of services provided and may account for different patterns of integration. Smaller, rural facilities -where the drops in integration were the steepest -may be impacted more than large, rural sites during such holiday periods.
It is also possible that provision of HIV and MCH services may fluctuate frequently or periodically, in patterns we could not detect from 5-day 'snapshot' assessments (regardless of their specific timing). An early evaluation of CDC's 'patient flow analysis' method, conducted over one day in family planning clinics in Kenya, concluded that: "the 'typical' clinic day does not really exist. The client/patient load and staffing patterns are likely to vary according to many factors: by day of the week, or season of the year, staff vacation or sickness, etc." 14 Assessments were extended to five days in this study, yet, neither does the 'typical' clinic week exist. It may be more informative to monitor over a longer period, for more representative data. However, the 5-day assessments proved challenging and resource-intensive to implement, and longer versions may be prohibitive in many settings. Previous evaluations of patient flow analyses also note that data may not be representative since staff -aware of the assessment -may try to perform at their best. 14 For these reasons, strengthening routine data collection systems may be preferable, but many existing systems record services individually in separate registers, and are thus unable to document service integration without fundamentally changing the system. It was this barrier that led us to utilise the client flow assessment.

Data sharing
The dataset will be made available via an LSHTM repository upon completion of the Integra Initiative.

Competing interests statement
The authors have declared that no competing interests exist.