All 16 high-priority HFs responded in detail to the HRH assessment and participated fully in on-site interviews. Results from the team’s initial data collections indicated that, contrary to initial conjecture, gross staffing level challenges were generally not an issue at the HFs. Exhibit 3 shows the staffing across all 16 sites by type of staff (e.g., doctor, nurse, midwife) and those who were trained in HIV/AIDS care and treatment. Full-time vs. part-time staffing is also noted. Total staffing numbers include non-HIV/AIDS-trained staff, but for the most part, HFs in aggregate were well-staffed for HIV/AIDS care.
An evaluation of HIV/AIDS caseload was then performed to determine if appropriate levels of HIV/AIDS-trained staff were in place at each HF. Exhibit 4 shows the HIV/AIDS case load (end of March 2019) for each site with the average load shown as a horizontal line. While midwives are needed across the board, only four sites (shown in red) required more HIV/AIDS-qualified health staffing (nurses), and only one site (shown in green) required more doctors and nurses. Thus only four of the 16 HFs required additional trained staff—not necessarily hired staff—in HIV/AIDS care and treatment. Only one site required increased (clinical) staffing.
From these analyses, the team concluded that having enough staff was not a key HRH issue and that, instead, other needs likely deserved more attention (aside from the clear HRH resource needs in the five sites mentioned in Exhibit 4). After compiling the qualitative results from the HF interviews, Exhibit 5 offers some interesting insights into HRH challenges in the HFs:
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While few barriers seem to be compensation-related, more HIV/AIDS clinical staff and training (clinical and non-clinical) are needed. Low morale seems tied to lack of job descriptions, evaluations, and career pathing
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Improvements in morale could lead to better recruiting and/or positive selection for employment at HFs, which could help “up-scale” these HFs [31, 32]
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Community activities are not well-organized due to lack of peer educators and community health worker training and oversight. Inconsistent oversight of and non-standard documentation from these workers is not only in the HIV/AIDS space but also in TB and malaria domains
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Work environments require improvement—spaces to collaborate, rest, etc.—and workers need more protective clothing and communities of interest to share / learn best practices
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Improved ART distribution would help as would access to more advanced therapies. Budgeting support will also help some individual HFs [33]
After a careful analysis of HF interview data, the team reviewed literature on HRH intervention research and determined that the barriers, above, could be addressed with interventions across the following six domains [34]:
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Staffing: Increasing clinical hiring (doctors, nurses, midwives) and peer educators, and optimizing time allocated to HIV/AIDS patients by these clinical resources
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Training: Training CHWs in HIV/AIDS-specific care protocols, improving job descriptions and expectations to enhance morale, and enhancing collaboration and management skills
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Workplace Environment: Providing opportunities for, renovating sites, implementing worker protections, and rewarding community involvement and site leadership
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Community Outreach: Working to bring more patients into the clinic, increasing screenings, and creating communities of interest to share best practices (sites and communities)
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Medical Supplies and Equipment: Providing access to advanced drugs and equipment, improving supply chains for ARTs, and helping sites better budget and report 95-95-95 progress
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Monitoring and Evaluation: Standardizing monthly reviews of 95-95-95 progress and collecting ongoing feedback on barriers to HRH effectiveness [35]
Determining responsible stakeholders for these interventions is also critical [36]. The team determined that four key stakeholders would be assigned responsibilities for any interventions across the six domains, above. Interventions would be implemented by all sites, selected sites, the MoH, and/or by ICAP. Exhibits 6A and 6B show the “universe” of proposed interventions by key stakeholder/responsible party. For example, in the “Training” domain, “All Sites” will need to provide more HIV/AIDS-specific training while only one “Selected Site” will need to hire dedicated HIV/AIDS staff members. The MoH would need to approve budget for such training and personnel, and ICAP would need to provide the proper job description(s) and training plan for new hires or training programs for existing HRH.
However, not all of these 35 interventions are of the same importance/urgency nor could all be launched simultaneously (assuming resources were even available to do so). Thus, the team constructed a set of prioritization criteria in order to stage and sequence these interventions in a more manageable way [37]:
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Desirability: Do HFs, the MoH, ICAP really want to pursue this intervention (based on past experience, etc.)?
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Feasibility: If the intervention is desirable, do HFs, the MoH, ICAP, etc. have the (non-financial) resources, skills, and tools ready to kick-off the intervention?
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Viability: If stakeholders have the skills and time, do they have the funding, or can they quickly get the needed it to fund the intervention?
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Sustainability: Once implemented, will the HRH interventions “stick;” i.e., will the improvements stand the test of time or be lost as just one-time changes?
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Time to Impact: Finally, if stakeholders implement an intervention, have skills to do it, and can be funded, will they see a return on their efforts based on meaningful and timely impacts?
After working with HFs, HRSA leadership, ICAP, and MoH, the team prioritized the interventions, and Exhibit 7 shows the results of this collaboration. Efforts were prioritized in terms of what needed to be implemented in the short-term (within the first six months), over the medium-term (within the following six months), and over the long-term (within the final six months of the total intervention time frame of 18 months). Exhibit 8 shows only the short-term interventions noting that two of them had already been started by C&T teams.
Based on successes of similar HRH interventions in other sub-Saharan contexts, the team expects to see several improvements [35]. These are aligned with the major HRH domains mentioned previously:
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Staffing: Increase numbers of patients tested/tested positive for HIV/AIDS and those treated if positive (including pregnant women) as more qualified health workers, midwives, and peer educators are put into the HRH workforce
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Training: Install more staff able to help HIV/AIDS patients, improve satisfaction, and enhance clinic leadership. These should create more awareness for clinics (or “pull”) for new and existing cases
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Workplace Environment: Improve workplace environments that lead to more team-based care, best practice implementations, and improved morale for staff
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Community Outreach: Create wider networks in the community and build trust with clinics. This will increase treated cases, follow-ups, lower viral loads, etc.
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Medical Supplies and Equipment: Deploy therapies to patients more quickly and give workers more security via enhanced protective equipment
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Monitoring and Evaluation: Place emphasis on achievement of 95-95-95 goals with standard reporting across clinics (and with MoH) to quickly implement best practices
To track these expected improvements, the team developed a comprehensive reporting system, using Microsoft Excel, that incorporates both monthly MER data, to track C&T improvements, and the HF interventions noted earlier. In this way, all stakeholders—HF leaders, C&T teams, ICAP staff, MoH, and HRSA—are able to view monthly progress updates, note where efforts are not meeting desired goals, and see corrective actions being taken to address shortcomings. Exhibits 9A (MER statistics) and 9B (site-level HRH interventions) provide snapshots as of November 2019 for these DRC HRH efforts.
The team hopes to use these data to perform program evaluations to determine intervention- and program-level effectiveness and to show how these efforts have led to better outcomes, as measured by MER reporting, than C&T interventions, alone, may have created.