A survey of health facilities providing antiretroviral treatment in Uganda has found that nearly two-thirds of those providing ART are not doctors, and report major gaps in training. Two out of every five of this group had received no training in starting patients on ART and two-thirds had not been trained in how to monitor patients on ART.
The findings were published in the August 23 edition of Human Resources for Health.
In self-assessment questionnaires seven percent of doctors, 42% of clinical officers, 35% of nurses and 77% of midwives thought their overall knowledge of ART was lower than “good”.
Task-shifting from physicians to nurses and clinical officers requires ongoing integrated trainings to ensure the correct use and monitoring of ART if toxicity and drug resistance are to be avoided and the success achieved to date in the management of HIV is to be maintained in resource-poor settings.
Access to ART continues to expand beyond urban centres into remote areas and task-shifting is widely acknowledged as a means to counter the challenge that the chronic shortage of healthcare personnel in resource-poor settings presents. Studies have demonstrated that in some cirumstances the quality of care provided by non-physician clinicians is equal to or better than that provided by clinicians.
The Infectious Diseases Institute (IDI) at Makerere University, Uganda together with the (Ugandan) Ministry of Health undertook a training needs assessment that focused on two of the World Health Organization’s recommendations for task-shifting in the promotion of access to HIV and other health care services:
- Recommendation Four: countries undertake or update a human resources analysis on the extent to which task-shifting is already taking place and
- Recommendation Nine: countries adopt a systematic approach to harmonised, standardised and competence-based training that is needs-driven and accredited.
A survey of health professionals and heads of antiretroviral therapy clinics from a stratified random sample of 44 of the country’s 205 accredited health facilities was undertaken. Six out of 12 catchment areas were chosen by a lottery method. The sample included six regional referral hospitals, 16 district hospitals and 22 health centres. Facilities were grouped as follows: ownership (government or non-governmental organisation and/or faith-based) and whether antiretroviral therapy was being provided.
A sample of health professionals was chosen in collaboration with the head of the ART clinic. Criteria included being present on the day the study team visited. Efforts were made to have at least one doctor, one clinical officer, one nurse and one midwife from each clinic.
Data collection involved self-administered questionnaires for individual health professionals and face-to-face interviews with the heads of the antiretroviral clinics.
Forty-three of the 44 facilities selected were included of which 38 provided ART and five (one district hospital and four health centres) did not.
Expansion of ART from urban clinics to district hospitals and primary care facilities is reflected in the numbers. Although regional referral hospitals provided ART to a higher proportion of people with HIV (45%) than district (33%) and health centres (17%) the authors suggest that over time these percentages may even out as care is transferred closer to accredited facilities near the patient’s home.
The sample comprised 265 clinicians: 34 doctors, 46 clinical officers, 124 nurses and 61 midwives. This distribution across professions was markedly different to the distribution of staff at ART clinics. Doctors were under-represented at all facilities, whereas nurses were over-represented at health centres and underrepresented at regional referral and district facilities. ART clinics at two district hospitals and two health centres had no doctors on staff.
ART tasks were performed by all staff interviewed. 64 percent of clinicians prescribing ART were clinical officers, nurses and midwives. The authors note that this task-shifting was in line with recommendations from experts and may well have contributed to increased access to ART.
The study revealed that training on starting and monitoring ART has not kept pace with task-shifting. Of those prescribing ART 35% had not been trained on starting ART and 49% had not been trained on the monitoring of ART. These percentages differed across health professions: 27% of doctors had no training on monitoring ART compared to 64% of other clinicians. Similarly 24% of doctors had no training on starting ART compared to 38% of clinical officers, 38% of nurses and 49% of midwives.
While higher percentages of doctors and clinical officers attended training on monitoring of ART and paediatric HIV care than nurses and midwives, a lower percentage of doctors and clinical officers attended training on voluntary counselling and testing than nurses and midwives.
Self-assessment of knowledge of ART also differed across professions and was closely related to training in starting and monitoring ART: Ratings were categorized as “excellent”, “very good” and “good” and were grouped together as “sufficient”. 75% of all respondents deemed their overall knowledge of HIV as sufficient and 40% rated their overall knowledge of ART as sufficient. 7% of doctors prescribing ART rated knowledge less than “good” compared to 48% of other clinicians.
Limitations noted by the authors include overrepresentation of certain professionals at some facilities and underrepresentation of others due to reliance on those present at accredited ART clinics on the day of the study.
The authors further note that of the 45 facilities in the sample two remote facilities were replaced by those easier to reach. Task-shifting and an absence of training, the authors believe, were more likely to occur in remote facilities so the sample may have underestimated the extent of task-shifting in addition to the associated ART training needs.
The authors suggest that this assessment provides an innovative method that can be replicated to inform ART trainings in the context of ongoing scale up and task-shifting. The authors conclude that “Training initiatives should be an integral part of the support for task-shifting and ensure that ART is used correctly and toxicity or drug resistance does not reverse the successes to date.”
Lutalo IM et al. Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda. Human Resources for Health 7:76, 2009.