Recommendations

Numerous benefits of FP/HIV service integration have been demonstrated, including increased access to both types of services, improved quality of care, and enhanced program effectiveness and efficiency (UNAIDS 2010). Yet while service integration is a key Global Health Initiative principle, its potential cannot be fully realized until there is a richer, widely disseminated evidence base not only on how integration affects service providers and other health workers, but also on how best to maximize positive effects and mitigate negative consequences.

We therefore recommend that to optimize service integration efforts, program managers and decision-makers should consider the following key questions during the planning, implementation, and evaluation stages:

• Negative effects of task shifting on health workers have been documented in other contexts. Which model(s) of task shifting would minimize these negative effects in the FP/HIV service integration context?

• Some health workers expressed enthusiasm for improving their skills and a desire to receive training, mentoring, and supportive supervision. What training, mentoring, and supervisory methods are most effective for ensuring provider capacity to deliver integrated services, during either preservice education or in-service training? For example, are there eHealth or mHealth methods that are more effective and/or efficient?

• Integration program designs must take into account potential conflicts between health workers’ attitudes toward clients and the intended delivery of integrated services. Which integration trainings have effectively incorporated content on provider attitudes toward clients, and what factors contributed to their success? What performance support mechanisms, such as clinical mentoring and supportive supervision, have reinforced positive attitudes toward clients during service delivery?

• Service integration may have unintended effects on health worker morale and job satisfaction, and in turn, on performance and productivity, when health workers feel unsupported. How should performance support mechanisms, such as compensation packages and supportive supervision, be structured to address health worker needs and increase the acceptability of service integration efforts by health workers? What lessons can be learned from CHW support mechanisms?

• Coordinating service integration efforts with health management teams can facilitate incorporation of client feedback, which can in turn contribute to boosting health worker morale. What are the characteristics of successful coordination models with health management teams in service integration contexts? What role does the health worker, including the community health worker, play in these models?

Health workers already play a key role implementing service integration efforts. Enabling them to fulfill this role requires that they also be more deeply involved in planning, monitoring, and evaluating FP/HIV service integration.