The goal of this qualitative study was to gain an in-depth understanding of frontline health workers’ ongoing experience with providing integrated HIV/AIDS and reproductive health services, and identify benefits and challenges faced by providers. In practice, providers reported delivering services in provider-level and unit-level integration, as well as a combination of both. The summary of benefits and challenges in Table
3 reveals a mixed experience of integration by providers in the study facilities at individual and operational levels.
Health care providers reported individual level benefits of integration that suggested many had successfully made the transition to integrated delivery. These included, at psychological level, job satisfaction and professional stimulation; but also, at more substantive level, providers felt they gained through enhancement of their skills and the broadened scope for experiential learning. Skill-enhancement and experiential learning opportunities that integration brings to a provider role through expansion of responsibilities has been reported in other previous case-studies
[18, 19]. However, these perceived benefits and motivational factors were countered by challenges that need to be dealt with if motivation to transform service delivery is to be maintained. In particular, many providers felt that their salaries were poor and incommensurate with their new set of integrated tasks and the associated workload. Many also suffered from increased occupational stress from treating severely ill, abused and poor clients, with no formal psychosocial support to help them cope. Majority said they improvised to ‘stress-relieve’ themselves. However, some providers reported that their supervisors organised occasional unwinding meetings to discuss occupational issues including stress, and the meetings seemed to work. Formalising regular debriefing or ‘unwinding’ meetings may provide an immediate and practical solution to occupational stress among staff in needy facilities.
At operational level, existing literature highlights a consistent list of issues relating to health service integration: workload, waiting times, contact session times, human resources, physical room space, equipment, drugs and other medical supplies
[1, 8, 10, 13–15]. While workload, waiting times, session times and human resources primarily pertain to the client-provider interaction; the rest of the issues represent ‘inputs’ or ‘resources’ that support the interaction to produce an effective and efficient integrated service. Both ‘client-provider interaction’ and ‘input’ issues were widely reported in this study too. Yet, as Table
3 indicates, operational level benefits were reported as well, notably: increased repeat visits and service uptake, increased willingness among clients to take an HIV test, and reduced loss of clients. These benefits, particularly, have been underscored as the core virtues of integration. Arguably, the certainty of these benefits may not be easily established without quantitative triangulation. However, reports of integration benefits represent positive provider perceptions about how well a new system is performing and these perceptions should be taken seriously and seized upon. Perceptions drive provider behaviour, which is central to the long term success of change and integration
A note about workload in relation to integration: health workers reported workload as being both attenuated and aggravated by integration. In literature, the general observation is that service integration tends to increase workload for the provider in the facility. Several factors have been associated with that increase in workload. For instance, in Ghana
, South Africa
, Kenya and Ethiopia
 increase in workload was found to be driven mostly by increased service uptake in the context of inadequate human resources. Another study in Ethiopia found that increase in workload during integration may also be due to expanded client-provider protocol that increases session times per contact with each client
. Both factors were reported in our study, with expanded protocol being the most associated with long waiting times due to increased session times per client. Our study directly suggests some solutions to the problem of increased workload and these were highlighted by providers who reported that integration had reduced their workload. Some providers attributed reduced workload to investments in human resource numbers ahead of integration; or changes in prescription policies especially in family planning counselling where emphasis has been more on long-acting contraceptives which translates into fewer clients returning in the short-term for ‘re-fills’ . Investment in human resource numbers reduced workload through client-load re-distribution, whereby previously uneven client-loads were now shared more evenly among a greater number of providers who offer more multiple services. With the potential that client-load re-distribution may lead to reduced queue-lengths per provider, managing workload may be key to mitigating the problem of long waiting times reported in this and other previous studies
[19, 22]. Both workload and long waiting times may also be addressed through managing client appointment times such that a reasonable number of clients are scheduled to visit each provider in the health facility on each day.
Finally, this study confirms previous studies on the impact of (usually pre-existing) service-guideline, infrastructural and logistic deficiencies (local service policies, physical space, information systems, equipment, drugs and other medical supplies) on the delivery of integrated services
[1, 14, 23]. Two specific examples just to illustrate: First, there were reported ambiguities surrounding the user-fee cost-sharing schemes currently in force which were unclear post-integration (something that has not been highlighted in the literature before); many providers called for clarity of user-charge policy for integrated services. Second, clinical recording procedures were fragmented still in pre-integration format, which compounded the workload challenge for providers and likely compromised integrity of the clinical information system, especially as a source of information for decision-making. Many of the providers recommended a single integrated clinical register for all services provided to a client in a session; and previous similar studies have identified efficiencies gained from integrated clinical information systems in an integrated service context
[19, 22]. But, beyond the effects of these (infrastructural and logistic) deficiencies in themselves, our findings illustrate the potential negative impact on provider motivation.
The promotion and introduction of integrated health services, like any form of organisational change, generates expectations in both providers and their clients. Thus, for providers resource shortages and weak support systems may be a source of occupational frustration and could affect their morale and overall productivity
. Because these problems tend to lie beyond the scope of facility-level decision-making, central level policy decisions need to take them into account right at the point of adopting integration as the new service delivery strategy in the health system. This qualitative study has helped highlight the fact that both pre-change and post-change phases are crucial to the success of integration as a service provision format at frontline health facilities. Central level health policy must lead the process of change to ensure that service delivery support systems and structures are adapted to the needs of integration; infrastructure is upgraded to ensure availability of sufficient room space in health facilities; and that medical supplies, utility services, and human resources are consistently sufficient; in addition to managing initial provider anxieties and other barriers to successful change. Once these have been addressed and the transformation accomplished, a subsequent focus should be on how to manage the post-change phase to ensure sustainability of the transformation. Previous work has noted the importance of commensurate staff incentives and benefits ‘packages’
[9, 12, 25] and that good management of the transformation process is key to sustaining successful change
[11, 12, 26] and effective delivery of health services after transformation
What was not done in this study, which might be attempted in future, is the linking of provider experiences at individual level to the model of integration in operation and actual performance of their facility. This study focussed on bringing out the issues; more complex linking analyses will be the next logical step.