1. Task Shifting, Service Coverage and Service Quality: Preliminary Findings from 2 Districts of Malawi By John Kadzandira PhD Researcher, RCSI (ChRAIC Programme)

2. Outline of the Presentation Study background, aims and objectives Study design, methods and status of data collection Findings Conclusions and Recommendations (Preliminary)

3. Study background, aims and objectives Malawi continues to face HR problems BUT still needs to provide services to all residents From 2004/05, Malawi has received huge external support for HIV & AIDS (GFATM, WB, pooled donors etc.) Rural areas were still underserved (even with these external funds) because of HR shortfalls (among other reasons) BUT HOW to scale-up without HR? Solution: TASK SHIFTING – Using community health workers (Health Surveillance Assistants) to provide HTC – Using CBOs, lay councillors & expert patients – etc.

4. Study background, aims and objectives; Cont’d The study is being conducted to assess: – The impact of task shifting on the quality of HIV services – The coverage of both HIV and community-level PHC which HSAs are primarily meant for Study being done in Salima and Mangochi districts (formerly of SWEF-GHIN study –........the 2 districts had mixed trends for HIV and non HIV services between 2005 and 2008)

5. Study design & methods – (Design: Cross-sectional exploratory mixed methods study ObjectiveData collection methodsStatus of data collection Assessing the impact of task shifting on the quality of HIV services 1. In-depth interviews with HTC supervisors & facility managers 2.HTC Observations 3.Exit interviews with clients Done 1 2 & 3 to be done Assessing the coverage of both HIV and community-level PHC 1.Record reviewsDone Assessing factors determining successful task shifting 1.Interviews with HSAs 2.Interviews with facility managers and national stakeholders Underway

6. Findings – Service coverage (service trends since 2005/6) HSA numbers jumped astronomically between 2006 and 2007 (with GF support) Modest increases observed in numbers of clinicians and nurses (declining in rural areas) HTC and ART clients rose dramatically between 2006 and 2009 (signifying HSA contribution and annual HTC campaign weeks) Declines or stable statistics observed for Pentavalent and FP especially between 2008 and 2010 Statistics for community level interventions being collected at the moment

7. Service trends cont’d Trend data (Mangochi district overall) – example:

8. Findings cont’d Has task shifting led to reduced workload among nurses and clinicians? – NO! (according to facility managers and nurses interviewed so far) With HTC increasing and stigma reducing, this meant more clients for ART, PMTCT and seeking other care PHC trends may be declining from two causes (according to facility and district managers): – Drug stock-outs and competing time demands between HIV and NON- HIV among HSAs

9. Are HSAs allocating time between HIV and Community PHC equally? – Not all HSAs are providing HTC services (some relief) – However, HSAs providing HTC allocating =>70% of time to HTC and facility based work than community work (n=45) “I like working in the HTC clinic rather than getting soaked in the rains.....repairing bicycles while in transit to or from the villages...”, female HSA, Salima

10. How about quality of HIV/HTC services? (perceptions of facility managers/clinicians & nurses) – Yes & No BUT “...half a loaf of bread is better than none....”, Nurse, Mangochi “...even highly qualified nurses and clinical officers also make mistakes, so don’t expect 100% from HSAs...”, District officer, Mangochi “we should guard against turning our HSAs into central (referral) hospitals....they shouldn’t do everything...”. MoH Official, Headquarters

11. Other issues coming out 10% of HSAs providing HTC in Salima never been on formal HTC training – According to 1 district informant – nurses/clinicians got trained but they don’t provide HTC (are in PMTCT & ART) – [Yet to compare HTC performance through observations with those formally trained] HSAs complaining of increased workload....amid long distances to catchment areas (those not residing there); no additional incentives for providing HTC alongside PHC

12. Discussion, Conclusions (preliminary) Evidence from data collected so far suggests that: – Task shifting to scale-up HTC using HSAs led to increased uptake of both HIV and non-HIV services – This created more work for nurses and clinicians Serving clients and completing M&E forms for multiple donors (even with the ‘3-Ones’ in place – There are doubts over the quality of HTC services being provided by HSAs (TO BE VERIFIED LATER THORUGH HTC OBSERVATIONS) – Community PHC services being sidelined where the HSA is providing both HIV and non-HIV services

13. Thank you!