title: The impact of HIV/SRH service integration on workload: analysis from the Integra Initiative in two African settings.
abstract: BACKGROUND
  There is growing interest in integration of HIV and sexual and reproductive health (SRH) services as a way to improve the efficiency of human resources (HR) for health in low- and middle-income countries. Although this is supported by a wealth of evidence on the acceptability and clinical effectiveness of service integration, there is little evidence on whether staff in general health services can easily absorb HIV services.
  
  
  METHODS
  We conducted a descriptive analysis of HR integration through task shifting/sharing and staff workload in the context of the Integra Initiative - a large-scale five-year evaluation of HIV/SRH integration. We describe the level, characteristics and changes in HR integration in the context of wider efforts to integrate HIV/SRH, and explore the impact of HR integration on staff workload.
  
  
  RESULTS
  Improvements in the range of services provided by staff (HR integration) were more likely to be achieved in facilities which also improved other elements of integration. While there was no overall relationship between integration and workload at the facility level, HIV/SRH integration may be most influential on staff workload for provider-initiated HIV testing and counselling (PITC) and postnatal care (PNC) services, particularly where HIV care and treatment services are being supported with extra SRH/HIV staffing. Our findings therefore suggest that there may be potential for further efficiency gains through integration, but overall the pace of improvement is slow.
  
  
  CONCLUSIONS
  This descriptive analysis explores the effect of HIV/SRH integration on staff workload through economies of scale and scope in high- and medium-HIV prevalence settings. We find some evidence to suggest that there is potential to improve productivity through integration, but, at the same time, significant challenges are being faced, with the pace of productivity gain slow. We recommend that efforts to implement integration are assessed in the broader context of HR planning to ensure that neither staff nor patients are negatively impacted by integration policy.
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. Sedona.Sweeney@lshtm.ac.uk.
authors.forename: Sedona
authors.initials: S
authors.lastname: Sweeney
authors.forename: Carol Dayo
authors.initials: CD
authors.lastname: Obure
authors.forename: Fern
authors.initials: F
authors.lastname: Terris-Prestholt
authors.forename: Vanessa
authors.initials: V
authors.lastname: Darsamo
authors.forename: Christine
authors.initials: C
authors.lastname: Michaels-Igbokwe
authors.forename: Esther
authors.initials: E
authors.lastname: Muketo
authors.forename: Zelda
authors.initials: Z
authors.lastname: Nhlabatsi
authors.forename: Charlotte
authors.initials: C
authors.lastname: Warren
authors.forename: Susannah
authors.initials: S
authors.lastname: Mayhew
authors.forename: Charlotte
authors.initials: C
authors.lastname: Watts
authors.forename: Anna
authors.initials: A
authors.lastname: Vassall
mesh_terms: D000349:Africa; D003153:Community Health Services; D003376:Counseling; D019033:Delivery of Health Care, Integrated; D003906:Developing Countries; D005260:Female; D006678:HIV; D015658:HIV Infections; D006801:Humans; D007182:Income; D008297:Male; D011181:Postnatal Care; D036301:Qualitative Research; D060728:Reproductive Health; D034121:Reproductive Health Services; D014937:Work; D000078329:Workforce; D016526:Workload
references.citation: Int J Health Plann Manage. 2010 Jan-Mar;25(1):17-29
references.pmid: 18770876
references.citation: Health Policy Plan. 2014 May;29(3):396-408
references.pmid: 23656700
references.citation: Soc Sci Med. 2008 May;66(10):2108-21
references.pmid: 18329774
references.citation: Lancet. 2004 Jul 3-9;364(9428):103-7
references.pmid: 15234864
references.citation: Stud Fam Plann. 2009 Sep;40(3):171-86
references.pmid: 19852408
references.citation: AIDS Patient Care STDS. 2012 Nov;26(11):662-73
references.pmid: 23078548
references.citation: Lancet. 2008 Feb 23;371(9613):668-674
references.pmid: 18295024
references.citation: Hum Resour Health. 2012 Oct 30;10:39
references.pmid: 23110724
references.citation: Hum Resour Health. 2008 Feb 07;6:3
references.pmid: 18257931
references.citation: Hum Resour Health. 2012 Feb 22;10:3
references.pmid: 22357353
references.citation: BMC Health Serv Res. 2013 Jan 11;13:18
references.pmid: 23311431
references.citation: Hum Resour Health. 2009 Dec 19;7:87
references.pmid: 20021682
references.citation: Hum Resour Health. 2011 Jan 11;9:1
references.pmid: 21223546
references.citation: J Int AIDS Soc. 2010 Jul 19;13:26
references.pmid: 20642843
references.citation: Health Policy Plan. 2014 Aug;29(5):570-9
references.pmid: 23894070
references.citation: Lancet. 2004 Nov 27-Dec 3;364(9449):1984-90
references.pmid: 15567015
references.citation: Health Serv Res. 1993 Dec;28(5):577-97
references.pmid: 8270422
references.citation: Health Policy Plan. 2010 Mar;25(2):104-11
references.pmid: 19917651
references.citation: Afr Health Sci. 2003 Dec;3(3):127-30
references.pmid: 14676718
references.citation: Hum Resour Health. 2010 Mar 31;8:8
references.pmid: 20356363
references.citation: Sex Transm Infect. 2012 Nov;88(7):498-503
references.pmid: 22859498
references.citation: Sex Transm Infect. 2012 Mar;88(2):85-99
references.pmid: 22158934
references.citation: BMC Public Health. 2012 Nov 13;12:973
references.pmid: 23148456
references.citation: BMC Health Serv Res. 2010 Sep 17;10:272
references.pmid: 20849626
references.citation: PLoS One. 2010 Jul 13;5(7):e11522
references.pmid: 20644629
references.citation: N Engl J Med. 2002 May 30;346(22):1715-22
references.pmid: 12037152
references.citation: Reprod Health Matters. 2003 Nov;11(22):51-73
references.pmid: 14708398
references.citation: PLoS One. 2013 May 16;8(5):e63328
references.pmid: 23696814