Productivity and performance of health workers

While it is common for health workers to express concerns about their working environment, occupational hazards are frequently cited as a source of demotivation in the context of FP/HIV service integration, affecting both the ability and willingness to deliver integrated services:

In settings with high HIV prevalence, the impact of the HIV pandemic has been shown to have a considerable impact on staff capacity and motivation. HIV-related illness among staff is an additional barrier to service provision […], and in some countries attrition of staff due to HIV/AIDS is deemed a serious system-wide constraint […]. Furthermore, within [sexual and reproductive health] facilities with newly integrated HIV services, the fear of occupational exposure and negative attitudes toward HIV-infected clients make some providers unenthusiastic about providing these services […] (Church and Mayhew 2009, 177).

Providers often cite high workloads as a disadvantage of FP/HIV integration. Interviews with providers and program managers elicit responses such as, “There are too many patients and too few health care workers” (Scholl and Cothran 2011, 11). In six studies that focused on providers’ experiences with integration, managers were concerned with both high workloads and the effect they may have on service quality (Dudley and Garner 2011). Adding services to already high workloads can even risk “crowding out” other existing health services (United States Government 2012, 8). Workload issues may also contribute to staff attrition.

In interviews with providers in 68 Ethiopian facilities offering integrated FP/HIV services, Mengistu et al. (2011) found that high seasonal workload, particularly in VCT clinics, and high turnover of trained staff were issues. Several recent studies cite providers’ fear that providing integrated services is too time-consuming (Nielsen-Bobbit et al. 2011; Kuria 2011; Awadhi et al. 2011), which might lead to burnout (Church, Simelane, and Mayhew 2010). One study found that FP/HIV service integration was not strongly associated with increased CHW productivity, possibly because the CHWs need more time per client than before integration (Creanga et al. 2007). As a result, the study recommended allocating resources to increase the number of CHWs. More research is necessary to confirm this finding, as it has implications for task shifting efforts.

As Church and Mayhew (2009, 177) note, “[d]espite these constraints, a few studies have documented program improvements and successes where service integration is properly supported and supervised.” The Integra Project launched peer mentoring to build integration capacity by “promot[ing] sharing of information between health workers to improve quality of care” and “introduc[ing] change in service delivery without removing staff from their workplace” (Ndwiga, Warren, and Abuya 2011, slide 4). Results included improved access to hormonal contraceptives; improved knowledge, skills, and use of long-term FP methods; an increased range of FP/HIV services at both FP and HIV facilities; and improved confidence and motivation. Further, Ndwiga, Warren, and Abuya (2011, slide 12) found that “peer mentoring is acceptable and feasible among first level health workers.” However, Hoke et al. (2011) found that while an intervention trial in South Africa was designed to provide on-the-job coaching to support FP service provision and referrals, some health workers did not follow the coach’s guidance. Nonetheless, several studies recommend supportive supervision and some form of mentorship (Gilmer and Baughan 2010; Mengistu et al. 2011; Pathfinder International 2011), to which Melaku et al. (2011) attributed the success of provider-initiated counseling and testing at FP units in health facilities in Ethiopia.

Support is also essential to enabling CHWs to effectively provide integrated FP/HIV services. In Tanzania, Zimbabwe, and Kenya, Pathfinder International promoted and trained former CHWs to act as supervisors (Banzi et al. 2011; Extending Service Delivery Project 2011; Pathfinder International 2005). Monthly oversight meetings were held with current CHWs to exchange information, review progress and problems, and develop plans. This approach helped maintain quality assurance and manage CHW workloads (Extending Service Delivery Project 2011). In addition, establishing an effective referral system that links CHWs to health facilities was repeatedly identified as a key success factor for FP/HIV service integration (Banzi et al. 2011; Extending Service Delivery Project 2011; Pathfinder International 2005; Scholl and Cothran 2011; WHO 2009).  

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