The system-wide effects of task shifting on the supply and the demand sides are presented in turn. It is worth noting that some of the conceptualized effects presented in Table 3 were not applicable to our case study (such as lack of career path for new cadres or cost implications due to refresher training or supportive supervision), or were out of the scope of this study (such as impact of the strategy on efficiencies or inefficiencies in health service delivery) so were not addressed below. Others (such as patient satisfaction and cost borne by patients and families for HIV care and treatment) were studied in detail in another study  so we used these data in our case study.
System-wide effects of task shifting on the supply side
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.
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".
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”.
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”.
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.
System-wide effects of task shifting from the demand side
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%) .
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.