A survey of health facilities providing anti retroviral 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 igoodi.
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 centers 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 circumstances 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, together with the 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.
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 centers. Facilities were grouped as follows: ownership (government or non-governmental organization and/or faith-based) and whether antiretroviral therapy was being provided.
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 centers and underrepresented at regional referral and district facilities. ART clinics at two district hospitals and two health centers had no doctors on staff.
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.
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.