Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique: A qualitative interview-based study with Ministry of Health leaders, clinicians, and donors

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Study Justification:
– Task shifting is a common strategy to deliver antiretroviral therapy (ART) in resource-limited settings.
– Consensus among stakeholders is necessary to formulate clear national policies that maintain high-quality care.
– This study aimed to understand key stakeholders’ opinions regarding task shifting of HIV care in Mozambique and to characterize which specific tasks stakeholders considered appropriate for specific cadres of health workers.
Study Highlights:
– 62 stakeholders were interviewed, including Ministry of Health leaders, clinicians, and donors.
– Stakeholders were highly supportive of physician assistants performing simple ART-related tasks.
– Stakeholders unanimously opposed community health workers providing any ART-related services.
– Motives to implement task shifting included increasing ART access, decreasing physician workload, and decreasing patient wait time.
– Chief concerns included reduced quality of care and poor training and supervision.
– Clinicians were more likely to support task shifting than policy and program leaders.
– Harmonizing policy and program managers’ views with those of clinicians will be important to formulate and implement clear policy.
Study Recommendations:
– Delegation of ART-related tasks to lower health worker cadres should be considered.
– Specific recommendations include allowing general mid-level nurses to initiate ART in adults and pregnant women, and allowing physician assistants to change ART regimens in adults.
– Quality of care and training and supervision of non-physician health workers should be ensured.
Key Role Players:
– Ministry of Health leaders (national and provincial levels)
– Representatives from donor and non-governmental organizations (NGOs)
– HIV clinicians providing care and treatment
– Provincial chief medical officers and heads of HIV programs
– Clinical leadership and staff in MoH-run health facilities
Cost Items for Planning Recommendations:
– Training programs for lower health worker cadres
– Supervision and mentorship programs
– Equipment and supplies for ART provision
– Monitoring and evaluation systems
– Support for quality improvement initiatives
– Coordination and collaboration efforts between stakeholders

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative interview-based study conducted with key stakeholders in Mozambique. The study used a semi-structured interview approach and included representatives from the Ministry of Health, donors, NGOs, and clinicians. The study provides insights into stakeholders’ opinions regarding task shifting of HIV care and identifies specific tasks that stakeholders considered appropriate for different cadres of health workers. The study had a relatively small sample size of 62 stakeholders and was conducted between November 2007 and June 2008. To improve the strength of the evidence, future studies could consider increasing the sample size, conducting interviews with a wider range of stakeholders, and including more recent data.

Background: Task shifting is a common strategy to deliver antiretroviral therapy (ART) in resource-limited settings and is safe and effective if implemented appropriately. Consensus among stakeholders is necessary to formulate clear national policies that maintain high-quality care. We sought to understand key stakeholders’ opinions regarding task shifting of HIV care in Mozambique and to characterize which specific tasks stakeholders considered appropriate for specific cadres of health workers. Methods: National and provincial Ministry of Health leaders, representatives from donor and non-governmental organizations (NGOs), and clinicians providing HIV care were intentionally selected to represent diverse viewpoints. Using open- and closed-ended questions, interviewees were asked about their general support of task shifting, its potential advantages and disadvantages, and whether each of seven cadres of non-physician health workers should perform each of eight tasks related to ART provision. Responses were tallied overall and stratified by current job category. Interviews were conducted between November 2007 and June 2008. Results: Of 62 stakeholders interviewed, 44% held leadership positions in the Ministry of Health, 44% were clinicians providing HIV care, and 13% were donors or employed by NGOs; 89% held a medical degree. Stakeholders were highly supportive of physician assistants performing simple ART-related tasks and unanimous in opposing community health workers providing any ART-related services. The most commonly cited motives to implement task shifting were to increase ART access, decrease physician workload, and decrease patient wait time, whereas chief concerns included reduced quality of care and poor training and supervision. Support for task shifting was higher among clinicians than policy and programme leaders for three specific task/cadre combinations: general mid-level nurses to initiate ART in adults (supported by 75% of clinicians vs. 41% of non-clinicians) and in pregnant women (75% vs. 34%, respectively) and physician assistants to change ART regimens in adults (43% vs. 24%, respectively). Conclusions: Stakeholders agreed on some ART-related task delegation to lower health worker cadres. Clinicians were more likely to support task shifting than policy and programme leaders, perhaps motivated by their front-line experiences. Harmonizing policy and programme managers’ views with those of clinicians will be important to formulate and implement clear policy.

Data were collected in semi-structured, one-on-one interviews that were conducted with individuals intentionally selected by two individuals (K.S. and a senior Ministry of Health manager) to represent the key stakeholders in the development of MoH policies for the provision of HIV care in Mozambique, including (1) MoH leadership at the national and provincial levels, (2) health sector representatives of donors and NGOs at the national level, and (3) HIV clinicians providing HIV care and treatment in six public hospitals that had pioneered ART delivery in Mozambique leading up to, and during, the initiation of the national HIV Care and Treatment Program (between 2002 and 2004). For the MoH leadership at a national level, we mapped out the key individuals based on leadership positions and/or programmatic relevance (i.e., heads of programmes germane to each topic). All but two of the recruited individuals consented to be interviewed and were interviewed. For MoH staff at a provincial level, we selected provinces from the north, south, and central regions (two provinces per region) and targeted the provincial chief medical officer and head of the HIV programme; those present on the day of the interviews were interviewed. For hospital staff, we targeted MoH-run health facilities providing ART and selected purposively to overlap with the provinces we were visiting to interview MoH provincial staff. We attempted to interview clinical leadership and a non-random sample of clinical staff in these facilities based on availability, until saturation was reached. For leaders of NGOs and donors, we listed the key donors and NGOs in Mozambique at the time and reached out to the individuals involved in policy development, support for public HIV care, or provision of HIV care (one individual per organization). There were no exclusion criteria for any of the groups. The study instrument (Additional file 1) was developed to include both closed- and open-ended questions, with the intent of characterizing respondents’ perceptions regarding task shifting in general and regarding the shifting of specific ART-related tasks to lower-level health cadres. Interview questions were tested for understandability and contextual appropriateness in a small number of individuals (representing national and provincial leadership, NGO/donors, and clinicians, reflecting similar backgrounds to respondents) before interviewing respondents. All interview questions were developed in Portuguese, all respondents spoke Portuguese, and all interviews were conducted in Portuguese. Interviews were not recorded. All interviews were conducted in the private offices of interviewees or in private spaces in HIV clinics. Notes were taken in Portuguese by the data collection team. The data collectors recorded responses to open-ended questions as summary statements. If the question or answer was not clear, the interviewers repeated the question, or repeated their interpretation of the respondent’s answer, to ensure that the message was mutually understood. Interviewers collected data on interviewees’ demographics, education, and employment using closed-ended questions. Attitudes about the delegation of tasks to different levels of health-care workers were ascertained using both closed- and open-ended questions. For each of seven cadres of health workers in Mozambique (Table 1), interviewees were asked whether the given cadre should perform each of eight tasks related to the provision of ART (yes/no): initiate ART in adults, pregnant women, adults with tuberculosis, or children; follow adults or children after ART initiation; change ART regimen in adults or children. These tasks were chosen based on our experience, because they would be more representative of key steps to expanding and sustaining ART coverage. In presenting results, we ordered tasks from simple (e.g., following patients in whom ART has already been initiated) to complex (e.g., changing ART regimen in a child), based on the proportion of participants who thought that a given task would be appropriate to delegate to lower cadre health workers. Finally, interviewees were asked to give up to three benefits and up to three risks of delegating ART tasks to physician assistants and up to three suggestions to ensure the quality of services provided by non-physician health workers. All interviews were conducted by one of three people and took place in person between November 2007 and June 2008. Relevant cadres of non-physician health workers in Mozambique, by training level Abbreviations: SMI, saúde maternal e infantil; MCH, maternal and child health. aInformal cadre. The frequencies of responses to closed-ended questions were tabulated overall and by employment of the respondent (policy-maker/clinician/donor or NGO worker) using simple percentages. Tables presenting the percentage of respondents who thought that a given health worker should perform a given task were colour-coded to highlight the direction and magnitude of agreement among respondents. Ranges for the colour-coding were chosen to highlight near-universal support (≥90% in darkest green) or opposition (<10% in darkest red) of the use of specific cadres to perform specific tasks; the width of the ranges was slightly larger for middle-level agreement (e.g. 40% to <60% was colour-coded white). Open-ended answers were analysed thematically to identify the most commonly cited responses. This content analysis focused on the most common answers, though all responses were tabulated and included in the results. We chose not to report p values because the goal of this study was not to test a hypothesis or to draw inferences beyond the study sample, but rather to describe major themes in the attitudes of stakeholders. All analyses were conducted using Stata, version 13.1 (College Station, TX). This study was approved by the Institutional Review Boards at the University of Washington and the Ministry of Health of Mozambique. All respondents provided written consent to study participation prior to being interviewed.

The study titled “Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique: A qualitative interview-based study with Ministry of Health leaders, clinicians, and donors” explores the opinions of stakeholders regarding task shifting of HIV care in Mozambique. The study aims to understand which specific tasks stakeholders consider appropriate for specific cadres of health workers.

The study collected data through semi-structured, one-on-one interviews conducted with key stakeholders involved in the development of Ministry of Health (MoH) policies for HIV care in Mozambique. The stakeholders included MoH leadership at the national and provincial levels, representatives from donors and non-governmental organizations (NGOs), and HIV clinicians providing care and treatment in public hospitals. The interviews were conducted between November 2007 and June 2008.

The study found that stakeholders were highly supportive of physician assistants performing simple antiretroviral therapy (ART)-related tasks. However, there was unanimous opposition to community health workers providing any ART-related services. The most commonly cited motives to implement task shifting were to increase ART access, decrease physician workload, and decrease patient wait time. Chief concerns included reduced quality of care and poor training and supervision.

Support for task shifting was higher among clinicians than policy and program leaders for specific task/cadre combinations, such as general mid-level nurses initiating ART in adults and pregnant women, and physician assistants changing ART regimens in adults.

In conclusion, stakeholders agreed on some ART-related task delegation to lower health worker cadres. Clinicians were more likely to support task shifting than policy and program leaders, possibly due to their front-line experiences. Harmonizing the views of policy and program managers with those of clinicians will be important in formulating and implementing clear policies.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the study titled “Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique: A qualitative interview-based study with Ministry of Health leaders, clinicians, and donors” is to implement task shifting in maternal health care.

Task shifting is a strategy that involves delegating specific tasks from higher-level health workers to lower-level health workers. In the study, stakeholders were supportive of delegating certain tasks related to antiretroviral therapy (ART) to lower-level health workers, such as physician assistants. This approach can be applied to maternal health care as well.

By task shifting in maternal health care, certain tasks that do not require the expertise of a physician can be delegated to lower-level health workers, such as midwives or community health workers. This can help increase access to maternal health services, especially in resource-limited settings like Mozambique.

Some specific tasks that can be delegated to lower-level health workers in maternal health care include prenatal check-ups, basic antenatal care, postnatal care, and counseling on family planning methods. By allowing lower-level health workers to perform these tasks, the workload of physicians can be reduced, and patients can receive timely and quality care.

However, it is important to ensure that proper training and supervision are provided to the lower-level health workers to maintain the quality of care. This can be achieved through comprehensive training programs and regular monitoring and evaluation of the task shifting initiative.

Implementing task shifting in maternal health care can help address the shortage of skilled health workers and improve access to essential maternal health services, ultimately contributing to better maternal and child health outcomes.
AI Innovations Methodology
The study described in the provided text focuses on understanding key stakeholders’ opinions regarding task shifting of HIV care in Mozambique. Task shifting is a strategy to deliver antiretroviral therapy (ART) in resource-limited settings by delegating specific tasks to lower-level health workers. The goal of the study is to gather insights from Ministry of Health leaders, clinicians, and donors to formulate clear national policies for task shifting in HIV care.

To improve access to maternal health, it is important to consider innovations that can be implemented. Some potential recommendations for innovation in this context could include:

1. Telemedicine: Using technology to provide remote consultations and support for maternal health, especially in rural or underserved areas where access to healthcare facilities is limited.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information, reminders, and support for pregnant women, including prenatal care, nutrition, and postnatal care.

3. Community-based interventions: Implementing community health worker programs that focus on maternal health education, early detection of complications, and referral systems to ensure timely access to healthcare services.

4. Task shifting: Expanding the roles and responsibilities of lower-level health workers, such as midwives and nurse practitioners, to provide comprehensive maternal health services, including antenatal care, delivery, and postnatal care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population group that will benefit from the innovation, such as pregnant women in a particular region or community.

2. Collect baseline data: Gather information on the current status of maternal health access, including indicators such as the number of antenatal care visits, facility-based deliveries, and maternal mortality rates.

3. Develop a simulation model: Create a mathematical or computational model that represents the healthcare system and the potential impact of the recommended innovations. This model should consider factors such as population demographics, healthcare infrastructure, and resource availability.

4. Input data and parameters: Input the baseline data and relevant parameters into the simulation model, such as the coverage and effectiveness of the recommended innovations, as well as any potential barriers or limitations.

5. Run simulations: Use the simulation model to simulate different scenarios, such as the implementation of telemedicine, mHealth applications, community-based interventions, or task shifting. Evaluate the impact of each scenario on access to maternal health, considering indicators such as increased antenatal care coverage, reduced maternal mortality rates, and improved postnatal care.

6. Analyze results: Analyze the simulation results to assess the potential impact of the recommended innovations on improving access to maternal health. Compare the different scenarios and identify the most effective strategies.

7. Refine and validate the model: Continuously refine and validate the simulation model based on real-world data and feedback from stakeholders. This will ensure that the model accurately represents the healthcare system and provides reliable insights.

By following this methodology, policymakers and healthcare providers can gain valuable insights into the potential impact of different innovations on improving access to maternal health. This information can guide decision-making and resource allocation to prioritize the most effective strategies.

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