title: Antiretroviral treatment and the health workforce in South Africa: how have ART workers been affected by scaling up?
abstract: OBJECTIVE
  To investigate the effect of scaling up antiretroviral treatment (ART) on the working environment and motivation of health workers in South Africa; and to suggest strategies to minimize negative effects and maximise positive effects.
  
  
  METHODS
  Exploratory interviews with health managers and senior clinical staff were used to identify locally relevant work environment indicators. A self-reported Likert scale questionnaire was administered to a randomly selected cohort of 269 health professionals at health facilities in KwaZulu Natal and Western Cape provinces of South Africa that included ART delivery sites. The cohort was disaggregated into ART and non-ART groups and differences between the two compared with Fisher's exact test and the non-parametric Mann-Whitney U-test.
  
  
  RESULTS
  The ART sub-cohort reported: (i) a lighter workload (P = 0.013), (ii) higher level of staffing (P = 0.010), (iii) lower sickness absence (P = 0.032), (iv) higher overall job satisfaction (P = 0.010), (v) poorer physical state of their work premises (P = 0.003), and (vi) higher staff turnover (P = 0.036). Conclusion Scale-up affects the work environment in ways that influence workers' motivation both positively and negatively. A net negative balance is likely to drive staff out-migration, undermine the quality of care and compromise the capacity of the programme to achieve significant scale. As health workers are the most important element of the health system, a comprehensive and systematic understanding of scale-up impacts on their working conditions and motivation needs to be an integral part of any delivery strategy.
authors.affiliation: Institute for Health and Human Development, University of East London, London, UK. p.tobi@uel.ac.uk
authors.forename: Patrick
authors.initials: P
authors.lastname: Tobi
authors.forename: Gavin
authors.initials: G
authors.lastname: George
authors.forename: Elena
authors.initials: E
authors.lastname: Schmidt
authors.forename: Adrian
authors.initials: A
authors.lastname: Renton
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D003906:Developing Countries; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control; D006306:Health Surveys; D006801:Humans; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D010563:Personnel Turnover; D012456:Salaries and Fringe Benefits; D013019:South Africa; D016526:Workload
chemical_list: D044966:Anti-Retroviral Agents