Key Research Findings
The Integra Initiative was research project on the benefits and costs of a range of models for delivering integrated HIV and SRH services in high and medium HIV prevalence settings (Kenya, Malawi, and Swaziland), to reduce HIV infection (and associated stigma) and unintended pregnancies.
For further information on the project questions and design, click here.
Findings from the project show that integrating HIV into SRH services is associated with:
- Better HIV testing outcomes
- More consistent condom use
- Improved or consistent quality of care
- Improvements in efficiency through better use of human resources
- Improved teamwork and provider motivation – if they feel supported by their managers
- Reducing stigma – if health staff are sensitive to fears and concerns and provide strong link to psychosocial support
- Supporting client choice – this is achieved if integration is bi-directional, i.e. HIV is integrated into SRH services but also SRH services are integrated into HIV services so clients can receive all their services in one place but different clients had different entry point preferences.
Further information about the research findings and links to relevant research papers can be found in the Frequently Asked Questions.
Steps to Integration
Based on the high-quality evidence gained through the Integra Initiative, if a health facility is considering integrating SRH and HIV services, it is important to think through the following steps in order to design an effective, realistic integration model:
Advocacy and consensus building on the level and content of integrated services at each level of healthcare is important for the success of service integration. National reproductive health and HIV integration policies, strategies, and packages can also provide the contextual background for offering the integrated services.
This is essential to determining the unique gaps that require support both before and during integration (including infrastructure and supply-chain issues, provider skill levels, and existing service dynamics). Particular attention should be paid to whether units have staffing shortages or surpluses, and to how services are allocated across staff within a facility, so that reallocation of service duties can efficiently and appropriately make use of existing and new human resources. Where feasible, additional staff should be planned for, or training and mentorship planned to transfer some skills to new staff (e.g. lay counsellor conducting HIV counselling and testing).
Ensuring a baseline of sufficient supplies and physical assets will help the entire facility function more effectively, especially when introducing a service integration scheme. Facilities planning to integrate should explore the possibility of re-organizing the available rooms to improve strategic (and where necessary, discrete) client-flow from one room to another.
Since providers will be the ones to carry out the service-level elements of integration, it is essential that their voices are brought into the design process and continually heeded throughout implementation. Successful integration requires a health system-wide commitment at both planning and implementation stages, and including providers throughout the process will help provider motivation as well as ensure that management of the integration process reflects the on-the-ground needs of the facility.
Mentorship programmes have been demonstrated to improve provider skills and improve the success of integration efforts. Challenges of this approach can be addressed by ensuring that the mentorship programme promotes flexibility and cooperation. If thoughtfully designed and implemented, mentoring has the potential to meaningfully combat problems of staff shortages by increasing the skills for existing staff, by existing staff, in a matter that is sustainable and cost-effective.
As the integration process is carried out, it is important to constantly re-assess the value and realism of the model, and recalibrate it as needed to ensure the integration model is appropriate for the facilities’ needs and abilities and sustainable in the long run.
Integration is not a strategy that is implemented only once. The dividends of integration will not simply self-deliver after a single change; integration is instead an ongoing process that must be consistently supported and recalibrated as needed.
After the initial change to an integrated model, the health system itself continues to flux as it had previously: staff get transferred or change careers, resource allocation changes with national or regional budget priorities, new health problems emerge that threaten status-quo of existing service delivery set-up, global guidelines circulate that sometimes challenge the existing system’s focus, etc. Therefore, a health programme (especially one that has newly integrated its services) must be constantly vigilant about effectively monitoring and responding to these ‘weather’ changes and make the necessary adjustments to the integration model.