Table 1 Health centre demographic information & features of HIV service scale up
Demographic features | Health centre 1 | Health centre 2 | Health centre 3 | Health centre 4 |
|---|---|---|---|---|
Designation | Urban | Rural | Urban | Peri-Urban |
Official catchment population* | 62,579 | 15,000 | 101,972 | 43,850 |
Official opening hours* | Day: 8:00–17:00 | Day: 8:00–17:00 | Day: 8:00–17:00 | Day: 8:00–17:00 |
Night: 17.30–7.30 | Night: 17.30–7.30 | Night: 17.30–7.30 | Night: 17.30–7.30 | |
Service departments** | OPD, MCH,TB, ART, LAB, EH | OPD, MCH,TB, ART, IPD, LAB, LABOUR, EH | OPD, MCH,TB, ART, LAB, EH | OPD, MCH,TB, ART, IPD, LAB, LABOUR, EH |
Professional staff* | 41 | 5 | 46 | 22 |
Lay staff*^ | 29 | 5 | 46 | 12 |
Common features of ART clinic establishment (c. 2005–2008) | • New stand-alone building for ART clinic in three sites (HC1, HC3, HC4) | |||
• Externally funded/supported supply chain & laboratory services | ||||
• Recruitment & training of adult & peadiatric peer educators/Establishment of peer support groups | ||||
• NGO funded/run in-service training for select professional staff | ||||
• Donor-funded ‘overtime’ payments for professional staff working in the ART clinics | ||||
• NGO supported quality assurance systems | ||||
• Electronic medical records in three sites (HC1, HC3, HC4); ART specific stationary at all sites. | ||||
Common features of ART clinic scale-up & transition (c. 2009–2011) | • Removal of donor-funded overtime payments | |||
• Scale up of MoH-run HIV in-service training for all professional staff | ||||
• Formal inclusion of ART clinic services in routine duties of all professional staff | ||||
• Scale-back in NGO support for lay personnel (including peer educators & defaulter tracing) | ||||
• Scale-back in NGO support for quality assurance programs | ||||
• Externally funded but MOH managed ART supply chain | ||||
Common effects of ART clinic on facility operations & relationships | • Improved infrastructure & technical capacity to deliver ART. | |||
• Early improvements in HCW motivation and clinical standards in ART department. | ||||
• Lay personnel enabled efficient administrative & non-clinical functions in ART department. | ||||
• Early intra-cadre jealousies around opportunities for HIV training, overtime payments and better work conditions in ART clinics. | ||||
• Additional fragmentation (stand-alone ART clinics) of health centre management & operations. | ||||
• Strong perception amongst providers that HIV services were exceptional to their core duties (especially HC1, HC2, HC3). | ||||
• Perceptions that HIV services constituted additional/over work, undermining staff morale and service values. | ||||
Particular effects of ART clinic on facility operations & relationships | Enduring intra-cadre jealousies around overtime payments & superior work conditions in stand-alone ART clinic continued to undermine provider cooperation & continuity of care between ART clinic and other departments. | Small cadre of professional staff frequently overwhelmed by requirements of additional HIV services. Effects exacerbated by weaker supervision & quality assurance afforded to rural (as opposed to urban) sites. | Very large patient numbers & decreasing NGO support for lay personnel in scale-up phase led to marked decline in administrative functionality (e.g. missing files; queue bunching) and frequent patient-provider confrontations. | Overall in-charge able to use early gains in performance standards & staff morale in ART clinic to strengthen overall operations via whole-of-clinic meetings/integrated OPD/ART service delivery as levers. |