Original Article
Exploring task-shifting practices in antiretroviral treatment facilities in the Free State Province, South Africa Katinka de Wet a, * , Edwin Wouters a,b , and Michelle Engelbrecht a a Centre for Health Systems Research & Development, University of the Free State, South Africa, IB 39, PO Box 339, Bloemfontein 9301, South Africa. E-mail:
[email protected] b
University of Antwerp, Edegem, Belgium.
*Corresponding author.
Abstract There is good progress with the implementation of South Africa’s antiretroviral treatment program. The country, however, faces human resource shortages that could be addressed through appropriate task shifting. During 2009, we studied task shifting from nurses to community health workers (CHWs) for HIV treatment and care at 12 primary health-care clinics in Free State Province, South Africa. We found inefficiency in nurse deployment, and nurses spent considerable time on training, counseling, and administrative tasks that could be shifted to CHWs. Such a shift will require the South African Ministry of Health to recognize CHWs formally in the health system. Journal of Public Health Policy (2011) 32, S94–S101. doi:10.1057/jphp.2011.30 Keywords: task shifting; nurses; community health workers; human resources; HIV/AIDS; South Africa
Background The South African antiretroviral treatment (ART) program outcomes appear promising, with good adherence, survival, and retention rates.1–3 Furthermore, indicators of effectiveness of the ART rollout in the South African public sector are comparable to treatment provided in high-income countries.1–4 Human resources are critical to program success, especially in the Free State public health sector, where health worker vacancy rates approach 50 per cent.5
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101 www.palgrave-journals.com/jphp/
Task-shifting practices in antiretroviral treatment facilities
One approach to ameliorating the human resource crisis is ‘task shifting’, defined by the World Health Organization as: the rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highlyqualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health. (p. 2)6 Although not new, the concept of task shifting is gaining ascendancy in public health practice and research.7 The year 2010 heralded two important developments for task shifting in South Africa: the introduction of nurse-initiated ART, a task previously only performed by physicians; and the announcement that community health workers (CHWs) will be allowed, by law, to perform finger-prick HIV testing.8 We use the term ‘community health worker’ to include cadres sometimes called ‘lay workers’, ‘community care workers’, ‘home-based carers’, ‘directly observed treatment (DOT) supporters’, or ‘lay counselors’.9 CHWs may alleviate some human resource challenges facing publicsector facilities in low- and middle-income countries.10 As a ‘new mediating layer between the formal health system and citizens’ (p. 61),11 their potential contribution in South Africa is considerable. However, there is insufficient information on the extent to which task shifting is taking place in existing health services, the cadres affected, how it is being carried out, and its effects. We describe task shifting from nurses to CHWs for HIV treat ment and care at primary health care (PHC) clinics in the Free State Province, South Africa, in an attempt to begin to address these knowledge and information gaps. Although the province also suffers shortages of physicians, our exploratory study only focused on nurses and CHWs.
Methods The Ethics Committee of the Faculty of Health Sciences, University of the Free State, and the provincial Department of Health, approved the study. In 2009, the research team requested all nurses and CHWs who were on duty during field visits to 12 Free State Province PHC facilities to participate in the study. We gave questionnaires and covering letters
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101
S95
de Wet et al
to facility managers to distribute to nurses. Sixty-five nurses completed the questionnaires voluntarily and returned their self-administered completed questionnaires in sealed envelopes to a central point for collection. The structured questionnaire addressed the following aspects: respondent demographics; position held; formal training in ART treatment; total hours per day on providing ART, time spent on specific activities (for example, ART-related training); whether any of their tasks had been shifted, if so to whom, and the human resources problems experienced at facilities. The research team interviewed 37 CHWs, who volunteered to participate in the study, in their home language. The interview focused on: demographic information; number of patients cared for; whether home visits were undertaken; areas of formal training in ART treatment; time per week on ART activities; and tasks shifted from nurses to CHWs. We analyzed the questionnaires using SPSS version 17.
Results Nurses’ work hours and activities All participating nurses were full-time employees. Most were women (88 per cent) in the age group of 35–45 years. They reported working an average of 40 hours per week (range ¼ 30–45 hours) and 3 hours overtime per week (range ¼ 1–6 hours). On average, they spent 6.6 hours working in the ART section. Table 1 specifies the activities. Other reported activities included traveling (4.6 per cent), communication via fax and telephone (4.5 per cent), post-test counseling (4.3 per cent), and updating patient files and registers (1.8 per cent). Nurses were not asked how many patients they saw per day, and despite Table 1: Nurses’ time on antiretroviral treatment services Activity Training Data capturing Drawing blood Patient examination Pre-test counseling and patient information
S96
Minutes per day (mean)
Time in ART section (%)
62.7 56.6 51.0 46.6 40.0
19.4 17.5 15.8 14.4 12.8
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101
Task-shifting practices in antiretroviral treatment facilities
reporting spending 6.6 hours per day working in the ART section we found that ART-related activities accounted for only 5.4 hours per day. Many nurses reported spending time on ART-related training: eight in ten received training on ART adherence; and similar numbers attended training on ART side effects, drug resistance, and ART drug regimens. Only four nurses reported training in counseling/social support even though this activity is carried out by almost all nurses (97 per cent). Forty-two per cent of nurses indicated having shifted tasks to other professional nurses or CHWs (Table 2). The majority of CHWs were female (83.8 per cent), with 70 per cent under 40 years of age. On average, each CHW cared for 19 patients, of whom about eight were ART patients. CHWs worked half days, totaling approximately 20 hours per week, of which 15 hours were for ART-related activities. Only 12 of the CHWs reported doing home visits, each averaging five visits per week (Table 3). Other activities included training (5.7 per cent), traveling (3.4 per cent), updating files and registers (2.4 per cent), and communication (0.7 per cent).
Table 2: Task shifting from ART nurses to other staff or facilities Task shifted from art nurse
Task shifted to
ART patients: blood drawing, clinical monitoring, and patient follow-up (n=12)
Other PHC facilities (n=5) All PHC nurses at the facility (n=5) Staff nurses (n=1) Phlebotomists (n=1)
HIV counseling (n=10)
CHWs (n=9) All PHC nurses at the facility (n=1)
Drug readiness training (n=9)
CHWs (n=6) All PHC nurses at the facility (n=2) Nursing assistants (n=1)
Distribution of nutritional supplements (n=6)
CHWs (n=4) All PHC nurses at the facility (n=12) Dieticians (n=1)
Capturing and updating electronic information (n=4)
Data capturers or clerks (n=3) CHWs (n=1)
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101
S97
de Wet et al
Table 3: CHW time spent on ART activities per day Activity Pre-test HIV counseling Providing information to patients Post-test HIV counseling Providing care for ART patients Testing for HIV
Average hours per week
Working time (%)
8.2 6.6 5.2 3.4 2.6
27.7 22.3 17.6 11.5 8.8
More than 70 per cent of CHWs had received training on counseling and support, treatment adherence and drug resistance; and approximately 65 per cent were trained on side effects of ARV medication, nutrition for ART patients, and patient monitoring. We did not ask about duration of the training. CHWs reported several problems in their facilities: additional CHWs were required, training was inadequate, and staff motivation was poor (n ¼ 22; 62.9 per cent). They are remunerated around R1000 per month (US$141), and nine CHWs said they had taken a second job to augment their incomes.
Discussion We identified inefficiency in nurse deployment: nearly a fifth of their time was spent providing or receiving training and a similar proportion given to capturing of electronic patient records. As health facilities had employed data capturers since the inception of the ART program in the province, this work appears duplicative. Given government policies recommending nurse-initiated ART, it is crucial that there be a shift away from nurses performing the job functions that should be done by lower-level cadres of workers. Interestingly, nurses did not report spending time supervising CHWs, despite them working closely together. Respondents appeared unclear on the precise meaning of the term ‘task shifting’ – commonly interpreting it as a horizontal shift of tasks, those delegated to other nurses (such as HIV counseling, drug readiness training, distribution of nutritional supplements, and monitoring of patients). The only activities that were reportedly shifted vertically to CHWs were those that nurses did not see as among their primary responsibilities (drug readiness training and counseling).
S98
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101
Task-shifting practices in antiretroviral treatment facilities
CHWs are the principal recipients of tasks shifted downwards from nurses, and critical evaluation is needed to identify additional responsibilities, presently carried by nurses, which can be done by CHWs. Legislation, passed in 2010, now authorizes CHWs to conduct finger-prick HIV testing and is intended to markedly increase the role of CHWs in this service. However, as found in other countries, policymakers would need to address CHW training, their availability and remuneration, role clarity, and legitimacy.12 Nevertheless, taking on the task of HIV testing is a good example of how tasks, seemingly more specialized than counseling for example, can be shifted to CHWs. Limitations Our reliance on facility managers to distribute questionnaires to nurses means we cannot calculate how many questionnaires were actually distributed, or the response rate. Some study measures lacked sufficient specificity, such as the question on time spent in providing or receiving training. Reporting bias was incurred through the use of self-reported time spent on tasks, rather than direct observation. The totals of time disaggregated by task did not match the actual 40 hours in a work week.
Conclusion The results of the study suggest that nurses presently perform a disproportionate amount of tasks that can or should be done by CHWs. Task shifting, as a concept, has not been understood or implemented in a coherent or systematic manner, although the underlying conceptualization and support for such an initiative does exist. Evidence seems to suggest that CHWs remain an underutilized resource; although they have received some training, they are poorly paid, their tasks ill-defined, and are too-often viewed as a ‘flexible and semi-formal workforce on the margins of the health system, that can expand and contract easily as circumstances change’.9 The limited supervisory interaction reported by nurses suggests this might be the case. Indications are that the human resource shortages in the public health sector are set to continue, particularly in the face of a rapidly aging nursing population;13 attrition of the workforce due to illness, death, and migration; as well as a failure to produce sufficient numbers
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101
S99
de Wet et al
and categories of health personnel. These factors impact strongly on the sector’s ability to expand the country’s ART program successfully.6 The wide-scale implementation and formalization of a CHW program, which includes task shifting, presents a strategic opportunity for the country to address some of the broader human resource factors militating against the successful rollout of its ARV program and to harness the considerable potential resting in this cadre of worker. This requires the South African Ministry of Health to recognize CHWs formally in the health system.
Acknowledgements We thank the Development Economics Research Group (DERG) and the World Bank–Netherlands Partnership Program, the European Union-funded Program to Support Pro-Poor Policy Development (PSPPD) in the South African Presidency, and the University of the Free State, Health Economics and AIDS Research Division (HEARD), University of KwaZulu-Natal, and the UFS Strategic Cluster.
About the Authors Katinka de Wet, PhD, is a sociologist and researcher at the Centre for Health Systems Research & Development, University of the Free State, South Africa. Edwin Wouters, PhD, is a sociologist and works at the University of Antwerp, Belgium, and is also a research associate at the Centre for Health Systems Research & Development, University of the Free State, South Africa. Michelle Engelbrecht, PhD, is a senior researcher at the Centre for Health Systems Research & Development, University of the Free State, South Africa.
References 1. Wouters, E., Van Rensburg, H.C.J., Van Loon, F. and Meulemans, H. (2009) State of the ART programme: Clinical effectiveness and physical and emotional quality-of-life improvements in the Free State Province, South Africa. AIDS Care 21(11): 1401–1411.
S100
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101
Task-shifting practices in antiretroviral treatment facilities
2. Egger, M. (2006) The Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration, ART Cohort Collaboration (ART-CC) groups: Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: Comparison between low-income and high-income countries. Lancet 367(9513): 917–824. 3. Rosen, S., Fox, M.P. and Gill, C.J. (2008) Patient retention in antiretroviral therapy programs in sub-Saharan Africa: A systematic review. PLoS Medicine 4(10): 817–824. 4. Fairall, L.R. et al (2008) Effectiveness of antiretroviral treatment in a South African program. Archives of Internal Medicine 168(1): 86–93. 5. Health Systems Trust. (2009) Health statistics, http://www.hst.org.za/healthstats, accessed June 2010. 6. World Health Organization. (2008) Treat, Train, Retain. Task Shifting. Global Recommendations and Guidelines. Geneva, Switzerland: PEPFAR/UNAIDS. 7. Callaghan, M., Ford, N. and Schneider, H. (2010) A systematic review of task shifting for HIV treatment and care in Africa. Human Resources for Health, advance online publication 21 June, doi:10.1186/1478-4491-7-49. 8. Government Gazette. (2010) Regulations relating to the withdrawal of blood from a living person for testing, http://www.irinnews.org/pdf/Finger-prick_HIV_test_regulations.pdf, accessed October 2010. 9. World Health Organization. (2010) Global Evidence of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems. Geneva, Switzerland: WHO/Global Health Workforce Alliance. 10. Zachariah, R. et al (2009) Task shifting in HIV/AIDS: Opportunities, challenges and proposed actions for sub-Saharan Africa. Royal Society of Tropical Medicine and Hygiene 103: 549–558. 11. Schneider, H. and Lehmann, U. (2009) Lay workers and HIV programmes: Implications for health systems. AIDS Care 22(S1): 60–67. 12. Tantchou Yakam, J.C.Y. and Grue´nais, M.E. (2009) Involving new actors to achieve ART scaling-up: Difficulties in an HIV/AIDS counselling and testing centre in Cameroon. International Nursing Review 56: 50–57. 13. Lehmann, U. (2008) Strengthening human resources for primary health care. In: P. Barron and J. Roma-Reardon (eds.) South African Health Review 2008. Durban, South Africa: Health Systems Trust, pp. 163–177.
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S94–S101
S101
