title: Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique: a qualitative interview-based study with Ministry of Health leaders, clinicians, and donors.
abstract: BACKGROUND
  Task shifting is a common strategy to deliver antiretroviral therapy (ART) in resource-limited settings and is safe and effective if implemented appropriately. Consensus among stakeholders is necessary to formulate clear national policies that maintain high-quality care. We sought to understand key stakeholders' opinions regarding task shifting of HIV care in Mozambique and to characterize which specific tasks stakeholders considered appropriate for specific cadres of health workers.
  
  
  METHODS
  National and provincial Ministry of Health leaders, representatives from donor and non-governmental organizations (NGOs), and clinicians providing HIV care were intentionally selected to represent diverse viewpoints. Using open- and closed-ended questions, interviewees were asked about their general support of task shifting, its potential advantages and disadvantages, and whether each of seven cadres of non-physician health workers should perform each of eight tasks related to ART provision. Responses were tallied overall and stratified by current job category. Interviews were conducted between November 2007 and June 2008.
  
  
  RESULTS
  Of 62 stakeholders interviewed, 44% held leadership positions in the Ministry of Health, 44% were clinicians providing HIV care, and 13% were donors or employed by NGOs; 89% held a medical degree. Stakeholders were highly supportive of physician assistants performing simple ART-related tasks and unanimous in opposing community health workers providing any ART-related services. The most commonly cited motives to implement task shifting were to increase ART access, decrease physician workload, and decrease patient wait time, whereas chief concerns included reduced quality of care and poor training and supervision. Support for task shifting was higher among clinicians than policy and programme leaders for three specific task/cadre combinations: general mid-level nurses to initiate ART in adults (supported by 75% of clinicians vs. 41% of non-clinicians) and in pregnant women (75% vs. 34%, respectively) and physician assistants to change ART regimens in adults (43% vs. 24%, respectively).
  
  
  CONCLUSIONS
  Stakeholders agreed on some ART-related task delegation to lower health worker cadres. Clinicians were more likely to support task shifting than policy and programme leaders, perhaps motivated by their front-line experiences. Harmonizing policy and programme managers' views with those of clinicians will be important to formulate and implement clear policy.
authors.affiliation: Department of Global Health, Schools of Public Health and Medicine, University of Washington, Harris Hydraulics Building, 1510 NE San Juan Road, Box 357965, Seattle, WA, 98195-7765, USA. asilvis@uw.edu.
authors.forename: Alison S
authors.initials: AS
authors.lastname: Rustagi
authors.affiliation: Ministry of Health, Maputo, Mozambique. marlene.cuco@gmail.com.
authors.forename: Rosa Marlene
authors.initials: RM
authors.lastname: Manjate
authors.affiliation: Department of Global Health, Schools of Public Health and Medicine, University of Washington, Harris Hydraulics Building, 1510 NE San Juan Road, Box 357965, Seattle, WA, 98195-7765, USA. gloyd@uw.edu.|Health Alliance International, Seattle, WA, USA. gloyd@uw.edu.
authors.forename: Stephen
authors.initials: S
authors.lastname: Gloyd
authors.affiliation: Department of Global Health, Schools of Public Health and Medicine, University of Washington, Harris Hydraulics Building, 1510 NE San Juan Road, Box 357965, Seattle, WA, 98195-7765, USA. gjohn@uw.edu.|Department of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA, USA. gjohn@uw.edu.|Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA. gjohn@uw.edu.|Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA, USA. gjohn@uw.edu.
authors.forename: Grace
authors.initials: G
authors.lastname: John-Stewart
authors.affiliation: Department of Global Health, Schools of Public Health and Medicine, University of Washington, Harris Hydraulics Building, 1510 NE San Juan Road, Box 357965, Seattle, WA, 98195-7765, USA. mmicek@uw.edu.
authors.forename: Mark
authors.initials: M
authors.lastname: Micek
authors.affiliation: Health Alliance International, Seattle, WA, USA. sgimbel@uw.edu.|Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA, USA. sgimbel@uw.edu.
authors.forename: Sarah
authors.initials: S
authors.lastname: Gimbel
authors.affiliation: Department of Global Health, Schools of Public Health and Medicine, University of Washington, Harris Hydraulics Building, 1510 NE San Juan Road, Box 357965, Seattle, WA, 98195-7765, USA. ksherr@uw.edu.|Health Alliance International, Seattle, WA, USA. ksherr@uw.edu.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sherr
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003150:Community Health Workers; D003695:Delivery of Health Care; D005260:Female; D006077:Government Agencies; D015658:HIV Infections / Q000628:therapy; D006296:Health Services; D006801:Humans; D008297:Male; D008875:Middle Aged; D009073:Mozambique; D009726:Nurses; D010823:Physician Assistants; D010820:Physicians; D011247:Pregnancy; D036301:Qualitative Research; D014937:Work; D000078329:Workforce; D016526:Workload