Health workforce development
Whether existing or new staff provide integrated services, preservice education and in-service training are critical to success. In many cases, providers who are expected to deliver integrated services have not been sufficiently trained and/or do not consistently do so. Several studies of integration found that providers had not received any training in FP (Nielsen-Bobbit et al. 2011; FHI 2010b) or had limited or dated FP or HIV knowledge and skills (Farrell, Nagendi, and Efem 2011; Holt et al. 2011; Kennedy et al. 2011). This finding was supported by FHI’s five-country study that determined that up to two-thirds of providers did not have sufficient training, many providers were unaware of key guidelines, and there were misconceptions about methods and recommendations (FHI 2010a). Even in an intervention trial in South Africa that was designed to train providers in contraception for HIV-positive women, the training content was not translated into expected service delivery outputs (Hoke et al. 2011). Although over 90% of female clients in a separate South African study reported discussing condom use with HIV providers, less than 50% reported discussing non-barrier FP methods (Schwartz 2011). Conversely, Kinagwi and Kibet (2011) suggest that one of the contributing factors to a 123% increase in enrollment in four facilities in Kibera, Kenya, was increased staff capacity to provide integrated services. Indeed, several studies have found that providers prefer integrated care for sexually transmitted infections and HIV, training for which enhances their own skills (Fullerton, Fort, and Johal 2003; WHO 2003; Stein, Lewin, and Fairall 2008; Liambila et al. 2008). Community support and investment in provider training and supervision have been identified as success factors for integrated services (Kennedy et al. 2011), and providers have also expressed the need for more training on FP/RH issues (Church and Mayhew 2009; Awadhi et al. 2011; Church, Simelane, and Mayhew 2010).