Exploring the effects of task shifting for HIV through a systems thinking lens: the case of Burkina Faso

Training process and coverage

Training adopted a cascade model. The training of national trainers started in 2005. By 2008, 61% of the regional trainers had been trained and districts had started training their health staff. Primary health facilities started implementing task shifting in 2007. However, the high turnover made it impossible to achieve sustainable training coverage targets. According to an unpublished survey, 3/5 of health workers were not yet trained as of end of 2011. The duration of the training ranged from three days to one week. There was no difference in training duration by type of cadre. No refresher training was planned.

Supportive supervision

There was no plan for supportive supervision that is specific to the task shifting strategy for HIV. In 2006, only 46% of health facilities received at least two routine (not specific to HIV or task shifting) supervision visits per year. In 2007 this went down to 0.65%. In the subsequent two years, none received more than one routine supervision visit per year, if at all [19].

Access to VCT, PMTCT and ART services

While sites offering Voluntary Counseling and Testing (VCT) and Prevention of Mother to Child Transmission of HIV/AIDS (PMTCT) services have both increased, it was more so for PMTCT, see Figure 1. In 2009, 1288 (82%) health facilities provided PMTCT services and 192 provided VCT. This is illustrated by the higher percent of pregnant women having access to VCT, through PMTCT services, (around 50%) on average, compared to 16% in 2008 for the general population, Table 2.

The first level of care for initiation of anti-retroviral therapy (ART) and follow up is the district hospital or accredited community centres. The number of patients on ART has more than tripled between 2006–2010. However, 50% of people in need for ART were still uncovered by the end of 2010 [19], see Table 2.

Documents and records review

The documents review included reports describing the task shifting strategy and its implementation in Burkina Faso, as well as any progress reports or evaluations available from all stakeholders involved. The objectives of the review were to obtain a clear understanding of: (1) how the task shifting policy was conceived and what were its expected outcomes and targets; (2) how was the intervention implemented throughout the different implementation phases, including the expansion of coverage levels over time; (3) what are the available indicators of its health outcomes; (4) what were the important contextual factors relevant to understanding the impact of task shifting within the settings in which it was implemented and (5) any documented barriers to its implementation to date.

We also reviewed previous data and research on the topic, for example, on patient views and perception on the costs and quality of care for HIV services in Burkina Faso; as well as review of health information systems records and data collected from government sources (at all levels) and partners during the in-depth interviews.

In-depth interviews

Semi-structured interviews were conducted with various stakeholders, including health workers, to explore their experience and views with respect to the impact of task shifting, including the negative and un-intended effects on other health services, on human resources more broadly, and the system as a whole. Interview guides were tailored to each type of stakeholder to cover the relevant range of effects discussed in our conceptual framework and allowed for exploring additional effects from the perspective of the respondents through open ended questions, see Table 3.

A convenience sampling approach was used to select the study areas and respondents for the in-depth interviews. Out of the 13 regions in Burkina Faso, three regions were selected for the study (the east, the center and the south-west regions) to represent the different geographic characteristics and HIV prevalence rates in Burkina Faso. HIV prevalence is 0.7%, 1.7% and 3.1% in the east, south west and central regions, respectively [29].

In each region, one district was chosen. In the context of decentralization, districts have the responsibility for organizing primary health services for their population, where around 80% of health facilities are public and the remaining are private or faith-based [30]. HIV services are mainly provided in public and not-for-profit health facilities. In each district, one urban and one rural public health facility were selected for each level of care. Where there are community and/or faith-based health facilities, one of each type was selected. In each facility, the in-charge of the facility was selected for the interview. During the interview with the in-charge of the facility, health workers providing VCT or PMTCT services were identified. Among the health workers who are performing these services we selected one staff from each available cadre/level.

The total sample included 2 regional hospitals, 3 district hospitals, 6 primary health centres, 1 community-based facility and 2 faith-based facilities. Overall 10 urban and 4 rural facilities were included. A total of 19 key informants and 57 health workers were interviewed. Key informants were chosen from groups of Ministry of Health policymakers, development partners, professional associations and community based organizations. Interviews with health workers were conducted with doctors, pharmacists, nurses, midwives, community health workers, and other non-skilled workers from all the various types of public and not-for-profit health facility structures included in our sample.

Staff workload

Health workers' perception of workload was divided among health workers of all cadres. Some perceived an increased workload related to the additional administrative tasks of filling independent forms for HIV services. Others, particularly at the hospital level, have noted that the increase in workload is mainly a function of the reaction of some of their colleagues as this doctor at a district hospital explained: “the difficulty in our context is that, in structures with nearly 50 health workers, if one receives a specific training, the others tend to refer everyone towards that person. As a result the workload increases”. However, some respondents, particularly nurses at primary health centres, did not note an increase in workload and explained it by an adaptation and re-organization of services among staff at the facility level to accommodate for the additional services.

Staff motivation and performance

Several aspects of health workers motivation have been evoked. The need for carefully choosing health workers to be trained was raised. Some health workers were trained but due to lack of the necessary infrastructure and supplies they were not able to apply what they learnt, which several perceived as a waste and a source of frustration and therefore low motivation. On the other hand, it was also indicated that others who did not have this problem also did not implement the skills they have learnt due to lack of motivation or interest. As this trainer of trainers at national level explained: “Self-motivation of health workers is very important (…). There are some who only come to have the certificate for their CVs, and after the training they are not self-motivated to perform the new tasks”.

Another aspect of motivation that was brought up during the interviews was staff morale. Most of the health workers interviewed thought that in the absence of financial incentives, it is important to find other non-financial ways to motivate them. As a nurse in-charge of primary facility suggested, “even a letter of gratitude and appreciation of their work is comforting”.

Staff Turnover and coping mechanisms

New recruitments or re-assignments of staff due to the general problem of high staff turn-over in Burkina Faso was raised as a concern for the continuity and sustainability of the strategy. The need for staff training was, therefore, always felt. To mitigate this, some facilities have taken their own initiatives to find solutions. For example, using peer-training to ensure that all the personnel are involved in providing the various tasks to avoid the interruption of services in the absence of the trained staff member. This was mainly observed in primary health facilities in rural areas.

Job satisfaction

A positive effect that emerged through the interviews is increased sense of responsibility, competence, self-esteem and utility. As a district officer explained, the training and the expansion of tasks and responsibilities have made health workers realize that they can do tasks they previously did not think they can do. This not only gave them confidence in their ability to learn and acquire new skills but also gave them a sense of responsibility for delivering these new services.

In addition, the ability to use the acquired skills for non-HIV services was identified and appreciated by nurses and midwives as a source of satisfaction, where the training on management of opportunistic infections has reinforced their knowledge about other diseases, for example, on recognizing and treating respiratory diseases and dermatologic infections that in Burkina Faso they are authorized to manage given the shortage of doctors at that primary health facilities. It also improved their management of sexually transmitted diseases (STDs), where women attending the antenatal care or family planning clinics were, since they have been trained, systematically examined to exclude STDs, as explained by a midwife in a primary health facility.

Relationship between doctors and other staff

Another positive effect of the strategy that emerged from the interviews was a perception of improved relationships between doctors and other health staff. As this doctor at a district hospital explained: “yes! the workload has decreased, but also it makes you feel trusted! Because when you work with someone and you delegate certain tasks, the person feels appreciated and they do their work well! Consequently our relationship keeps improving".

Staff self-confidence

Despite the increased sense of utility and self-esteem, the majority of respondents, particularly nurses, brought the issue of lack of refresher training and specific supervision for the newly trained in task shifting as limiting factors for optimizing the impact of the strategy. This is exacerbated by the fact that routine supervision has been infrequent as described above. In the words of a nurse in-charge of a primary health facility: “I would particularly insist on the fact that it is always better when we intend to train people, that we always accompany this training with (…) the necessary technical support. This can be in terms of the necessary supplies, or in terms of refresher training to consolidate knowledge (…), or specific supervision (…), to assess implementation issues on the ground”.

Professional protectionism

Although the current strategy does not authorize nurses to initiate ART, we wanted to explore the views of doctors and nurses on what they think about this possibility. Their views were divided.

Nurses were generally in favour of delegating the initiation of HIV therapy to them. They argued that the shortage of doctors and the fact that nurses are the first line of contact with patients at primary health care facilities, are strong reasons for allowing them to prescribe.

As for doctors, some were in favour of task shifting because this would allow HIV services to be close to home. However, several doctors showed signs of professional protectionism, as illustrated in this statement by a doctor in a regional hospital: “May be the renewal of prescriptions can be done at the primary facility level, but not the initiation of the treatment. If we come to that, then doctors will have to make their bags and leave Burkina Faso to go to practice elsewhere. I think that is what we should do because if a nurse can do it, doctors will not have their place anymore”.

Staff frustration

The unavailability of medical supplies was perceived as one of the main problems facing the scaling up of the strategy, both for increased access to ARV and also for PMTCT and VCT. This was raised by several respondents as a reason for frustration and lack of motivation as they are unable to apply the skills they acquired during the training or provide the services that the population expects.

Information flows was another reason for frustration, where health workers at the periphery felt that they were not kept up to date with new information released at the national level, for example, on new lines of treatment for HIV/AIDS, something that they only get to know, accidently, through their colleagues in other regions.

Patients satisfaction with services received by lower cadres

Interviews with health workers, particularly nurses, at health facilities suggested that patients are generally comfortable with receiving clinical services from lower cadres. As a nurse at the regional hospital explained: “I can say that it is the paramedics that are in contact 24 /24 with the patient; compared to the doctor who only meets the patients during the consultation (…). Even the patients confuse the nurses and the doctors. They call everyone doctor. Quite often, some patients are more attached to the paramedics than to the doctor”.

In addition, the task shifting strategy was perceived to have also reinforced the relationship between the patients and health workers as this nurse in-charge of a primary facility explained: “the fact that you chat with the [pregnant] women when you do the counseling (…) creates a bonding and familiarity between you and the person (…). Often people even come to talk to me about their private life”.

Inequitable access to HIV services and increased financial burden for patients

Understanding the implications of the strategy on equitable access to HIV services was complex. On the one hand, our desk review demonstrated that population in rural areas are disadvantaged, both in terms of equitable access and reduced financial burden for obtaining HIV services, because laboratory testing, ARV initiation and refill are only available in urban areas, where district and regional hospitals are located. Moreover, most VCT centres are located in urban areas. Consequently, the financial burden on households for receiving HIV services remained high as demonstrated in a survey on access to, and costs of, HIV care and treatment in Burkina Faso, where, even if ARV was available free-of-charge, the majority of respondents complained about other costs such as food (91%), and transport (74%) [26].

On the other hand, some respondents, particularly community health workers, noted that for HIV, people prefer services far from home because of fear of stigma. They may, therefore, choose to incur the higher costs of travelling further away from home to mitigate the negative social effects of stigma. It is therefore unclear whether achieving better access to population in rural areas is desirable for them.