title: Shifting human resources for health in the context of ART provision: qualitative and quantitative findings from the Lablite baseline study.
abstract: Lablite is an implementation project supporting and studying decentralized antiretroviral therapy (ART) rollout to rural communities in Malawi, Uganda and Zimbabwe. Task shifting is one of the strategies to deal with shortage of health care workers (HCWs) in ART provision. Evaluating Human Resources for Health (HRH) optimization is essential for ensuring access to ART. The Lablite project started with a baseline survey whose aim was to describe and compare national and intercountry delivery of ART services including training, use of laboratories and clinical care.
  
  
  
  A cross-sectional survey was conducted between October 2011 and August 2012 in a sample of 81 health facilities representing different regions, facility levels and experience of ART provision in Malawi, Uganda and Zimbabwe. Using a questionnaire, data were collected on facility characteristics, human resources and service provision. Thirty three (33) focus group discussions were conducted with HCWs in a subset of facilities in Malawi and Zimbabwe.
  
  
  
  The survey results showed that in Malawi and Uganda, primary care facilities were run by non-physician clinical officers/medical assistants while in Zimbabwe, they were run by nurses/midwives. Across the three countries, turnover of staff was high especially among nurses. Between 10 and 20% of the facilities had at least one clinical officer/medical assistant leave in the 3 months prior to the study. Qualitative results show that HCWs in ART and non-ART facilities perceived a shortage of staff for all services, even prior to the introduction of ART provision. HCWs perceived the introduction of ART as having increased workload. In Malawi, the number of people on ART and hence the workload for HCWs has further increased following the introduction of Option B+ (ART initiation and life-long treatment for HIV positive pregnant and lactating women), resulting in extended working times and concerns that the quality of services have been affected. For some HCWs, perceived low salaries, extended working schedules, lack of training opportunities and inadequate infrastructure for service provision were linked to low job satisfaction and motivation.
  
  
  
  ART has been decentralized to lower level facilities in the context of an ongoing HRH crisis and staff shortage, which may compromise the provision of high-quality ART services. Task shifting interventions need adequate resources, relevant training opportunities, and innovative strategies to optimize the operationalization of new WHO treatment guidelines which continue to expand the number of people eligible for ART.
authors.affiliation: Dignitas International, Zomba, Malawi. juliennkhata@gmail.com.
authors.forename: Misheck J
authors.initials: MJ
authors.lastname: Nkhata
authors.affiliation: University of Zimbabwe, Harare, Zimbabwe.
authors.forename: Margaret
authors.initials: M
authors.lastname: Muzambi
authors.affiliation: MRC Clinical Trials Unit at University College London, London, UK.
authors.forename: Deborah
authors.initials: D
authors.lastname: Ford
authors.affiliation: Dignitas International, Zomba, Malawi.|Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
authors.forename: Adrienne K
authors.initials: AK
authors.lastname: Chan
authors.affiliation: Joint Clinical Research Centre, Kampala, Uganda.
authors.forename: George
authors.initials: G
authors.lastname: Abongomera
authors.affiliation: Joint Clinical Research Centre, Kampala, Uganda.
authors.forename: Harriet
authors.initials: H
authors.lastname: Namata
authors.affiliation: Infectious Diseases Institute, Makerere University, Mulago, Uganda.
authors.forename: Ivan
authors.initials: I
authors.lastname: Mambule
authors.affiliation: MRC Clinical Trials Unit at University College London, London, UK.
authors.forename: Annabelle
authors.initials: A
authors.lastname: South
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Revill
authors.affiliation: MRC Clinical Trials Unit at University College London, London, UK.
authors.forename: Caroline
authors.initials: C
authors.lastname: Grundy
authors.affiliation: University of Zimbabwe, Harare, Zimbabwe.
authors.forename: Travor
authors.initials: T
authors.lastname: Mabugu
authors.affiliation: Dignitas International, Zomba, Malawi.
authors.forename: Levison
authors.initials: L
authors.lastname: Chiwaula
authors.affiliation: University of Zimbabwe, Harare, Zimbabwe.
authors.forename: James
authors.initials: J
authors.lastname: Hakim
authors.affiliation: Joint Clinical Research Centre, Kampala, Uganda.
authors.forename: Cissy
authors.initials: C
authors.lastname: Kityo
authors.affiliation: University of Zimbabwe, Harare, Zimbabwe.
authors.forename: Andrew
authors.initials: A
authors.lastname: Reid
authors.affiliation: Infectious Diseases Institute, Makerere University, Mulago, Uganda.
authors.forename: Elly
authors.initials: E
authors.lastname: Katabira
authors.affiliation: Dignitas International, Zomba, Malawi.|Department of Family and Community Medicine, University of Toronto, Toronto, Canada.|Department of Family and Community Medicine, University Health Network, Toronto Western Hospital, Toronto, Canada.
authors.forename: Sumeet
authors.initials: S
authors.lastname: Sodhi
authors.affiliation: School of Population Health, University of Queensland, St Lucia, Australia.
authors.forename: Charles F
authors.initials: CF
authors.lastname: Gilks
authors.affiliation: MRC Clinical Trials Unit at University College London, London, UK.
authors.forename: Diana M
authors.initials: DM
authors.lastname: Gibb
authors.affiliation: MRC/UVRI Uganda Research Unit of AIDS, Entebbe, Uganda.
authors.forename: Janet
authors.initials: J
authors.lastname: Seeley
authors.affiliation: Dignitas International, Zomba, Malawi.
authors.forename: Fabian
authors.initials: F
authors.lastname: Cataldo
mesh_terms: D000554:Ambulatory Care Facilities / Q000458:organization & administration; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D017144:Focus Groups; D015658:HIV Infections / Q000188:drug therapy*; D019538:Health Care Surveys; D006282:Health Personnel / Q000193:education; D006801:Humans; D007588:Job Satisfaction; D008295:Malawi; D011057:Politics; D011320:Primary Health Care / Q000458:organization & administration; D036301:Qualitative Research; D019035:Rural Health Services / Q000458:organization & administration; D014454:Uganda; D000078329:Workforce; D016526:Workload; D015030:Zimbabwe
chemical_list: D044966:Anti-Retroviral Agents
keywords: ART decentralisation; HIV; Health Care Workers; Human Resources for Health; Malawi; Task Shifting; Uganda; Zimbabwe