Like much of Africa, provision of free ART services in Lusaka has created unprecedented health systems demand that cannot be met using traditional physician-dependent models. In our setting, we have attempted to utilize every available human resource to its full potential. Our three-pronged approach of training, mentorship, and continuous quality assessment has allowed the rapid roll-out of services despite notable resource constraints. Involvement of peer educators – mostly members of the surrounding communities – has helped to reduce stigma surrounding HIV and mobilize community leaders. The quality of care has not suffered, but has instead steadily improved under a structured program of assessment and targeted training.
The primary intent of our report is to describe our task-shifting strategy and provide basic data demonstrating feasibility. We are not in a position to perform a formal effectiveness analysis of our task-shifting approach – either as a package or by its individual components – because of insurmountable methodological difficulties in this programmatic setting (e.g. on-going nature of the clinical mentorship intervention, differences in patient volume and staffing among the sites, differing provider characteristics, possibility of temporal bias). Identification of a suitable comparator arm is also difficult because almost all the facilities we sponsor have at least some degree of task-shifting in place. Our inability to measure strategy effectiveness is a recognized limitation of this report. Nonetheless, we believe there are important lessons that come out of these experiences, particularly in the area of program design.
Various studies advocate greater use of lay health care workers in response to the human resource demands of HIV care and treatment . In Uganda, lay health workers have been trained to perform simple patient assessment and deliver antiretroviral medications to patients in their homes . In Zambia, the use of "adherence support workers" to provide clinic-based adherence counseling has resulted in reduced patient waiting times without comprise of adherence counseling quality . In our report, peer educators are only one component of the overall task-shifting strategy, making it difficult to determine their separate contribution to patient care outcomes. Nevertheless, we recognize the need for on-going supervision and performance evaluation for this newly established cadre of provider. At present, this includes daily on-site nursing supervision and site evaluations from peer supervisors on a regular basis. In addition, we are conducting follow-up research to determine patient and provider satisfaction with the peer educator strategy to objectively measure their effectiveness.
Although our model relies heavily on community members in routine care, it also promotes task-shifting within the health professions. We believe this to be a key component of our strategy's sustainability, since there are absolute limitations to the background knowledge and medical expertise that can be obtained by lay workers. Strengthening clinical abilities and experience among mid-level clinicians addresses the human resource crisis. Strategies such as this could also lead to improved job satisfaction and staff retention by reducing the risk of occupational burnout.
The clinic mentorship model described in this report is intensive and may be lengthy. On-site clinical mentorship for nurses, for example, usually lasts three months because of integration into often busy clinic flow. For this reason, we have only been only able to provide mentorship to 93 of 507 (18%) nurses and clinical officers who completed Ministry of Health-supported training workshops for adult HIV care and treatment. Our mentorship trainees were purposely chosen from senior members of staff, individuals experienced in clinical practice and teaching. The expectation is that these trainees will take on similar mentoring responsibilities for other providers on-site. We are currently developing appropriate monitoring strategies to ensure that lessons in basic clinical practices and HIV medical management are properly disseminated. This is a critical component to the sustainability of such a program, particularly as it rolls out into semi-urban and rural sites.
Strengths of this program are its focus on local capacity building and emphasis on clinical care quality rather than simple program indicators. One criticism has been its intensive use of resources; however, we believe this is justified, particularly during the early years of scale-up. The programs described in this report require trained personnel and central coordination, resources that may not be readily available in all African settings. This may be particularly true of rural settings where HIV prevalence and demand for services may be low. One possible adaptation would be the establishment of a few regional centers – likely in urban areas due to higher patient volumes – where providers can receive intensive training and then return to their primary facilities. Quality assessment could still be incorporated, though the frequency of visits may need to be reduced for feasibility.
To successfully bring this model to scale, engagement of local governments is an absolute necessity. One solution could be the integration of task-shifting into formal nursing curricula, with recognition of expanded duties via certification, legal support, and professional regulation. With such support, novel ventures such as nurse-led clinics could assist greatly with provision of necessary services [11, 12]. The government of Botswana has supported one such model, by institutionalizing the nurse practitioner degree in the 1980s . Similar efforts are possible in Zambia, but political and professional barriers must first be addressed at the national level . The curriculum for an HIV specialty certificate – one that would allow nurses to screen patients and initiate ART – has recently been approved locally in conjunction with the University of Zambia and the Nursing Council of Zambia. In a similar vein, the Zambian Ministry of Health is working with local partners to formalize a national training program for lay health workers such as peer educators. Such an initiative would standardize clinical skills and responsibilities of these lay workers and officially integrate them into the Ministry's personnel structure.