Characteristics of participating health facilities
Overall, 195 facilities across Uganda participated in the study. With regard to ownership-type, 121 (61%) were public facilities, while 35 (18%) were private-not-for-profit and 33 (16%) were private-for-profit. HIV research clinics in our sample were 6 (3%). In Uganda, HIV research clinics are specialized health facilities primarily engaged in HIV research (such as running HIV prevention clinical trials) but with a routine service delivery arm attending to regular patients.
Table 2 shows that by level of care in the Ugandan health system, the majority of participating facilities were Health Centre IVs (sub-district facilities) at 72 (36.9%). This was followed by district hospitals at 58 (29.7%).
In terms of setting, almost half of the health facilities 88 (45%) were based in peri-urban areas (urbanized parts of rural areas). This was followed by 78 (40%) health facilities which were located in urban settings while 29 (15%) of the facilities were based in rural settings.
The nurse in-charge: leadership roles in HIV clinics
Our cross-sectional survey reveals that across the 195 health facilities participating in the study, nurses were the most represented cadre of health workers reporting a role as ‘ART clinic manager’ or the overall leadership of HIV clinics. As Table 4 shows, 72 (36.93 %) of all the 195 HIV clinics in our sample were led by nurses. Clinical Officers were the second most represented cadre in the leadership of HIV clinics 66 (33.84 %). In Uganda, Clinical Officers (COs) are a mid-level cadre of health professionals below the ladder of physicians. They attend three years of post-secondary training in a non-university tertiary institution .
In the in-depth interviews with nurses, they described finding themselves in leadership positions in HIV clinics across Uganda. This was especially so in lower-level health facilities and was certainly the case in health facilities in rural settings. Rural health facilities are often shunned by more specialized health worker cadre. However, even in regional referral hospitals (such as PUB-02), the head of the stand-alone HIV clinic was a nurse.
Nurse-led HIV clinics in rural settings
Our survey findings reveal a rural-urban dichotomy with regard to the phenomenon of nurse-led HIV clinics. As Table 5 shows, most of the nurse-led HIV clinics were based in rural settings. However, nurse-led HIV clinics were fairly even across setting.
Our qualitative interviews with facility in-charges shed more light on why nurse-led HIV clinics were mostly in rural settings. This was explained by a facility in-charge of one of the case-study facilities selected for in-depth understanding of the human resources for health strategies adopted by providers.
‘Our district being in a rural setting, those high caliber cadres like the medical officers, the pharmacists, it is a challenge to attract and retain those people. For medical officers we had a very serious gap. That’s why nurses are our main hope’. Facility in-charge, PUB-03
Although nurse-led HIV clinics were more common in rural settings, during on-site visits to facilities participating in the national survey, it was not uncommon to find that nurses were ART clinic managers even in tertiary facilities which are predominantly in urban settings. This was certainly the case in several district hospitals we visited and even in a number of regional referral hospitals across the 10 sub-regions of Uganda we visited.
The management skill sets demanded by HIV clinic leadership
As overall leaders of HIV clinics, nurses reported that they were responsible for the day-to-day operational aspects of running these busy stand-alone HIV clinics. As such, they described finding themselves thrust in positions requiring generalist management knowledge and skills. Some of the management skills that were identified by ART clinic managers as critical include competencies in human resources management such as the need to motivate over-burdened staff, ensuring sufficient stock of ART commodities including managing situation of frequent ART stock-outs and even in resource mobilization for HIV clinics. These are areas requiring competencies that are not primarily covered during their pre-service training.
‘You suddenly find yourself heading the (HIV) clinic and handling crisis after crisis. Stock-outs are a chronic headache, absenteeism by some members of our staff, the CD4 machine has broken down. All these matters come to you as the sole solution provider’ ART clinic in-charge, PUB-02.
Nurse-centred HIV care models
Findings from our national health facility survey show that in 93% (181) of the 195 health facilities, non-physicians were engaged in the clinical management of ART, including in initiating this therapy. Facility in-charges explained that they had difficulty retaining highly trained cadre such as physicians. We found that several health facilities deliberately adopted nurse-centred HIV care models as a mitigation strategy. Nurses were relied upon as the primary cadre in providing and managing ART services including initiating therapy in a number of facilities. In a large mission hospital (PNFP-01), nurses were trained to be versatile in a wide range of tasks within the HIV clinic. This was described by the ART program manager of one of the mission hospitals as follows:
‘I think my nurses are the best asset I have here. HIV has brought out the potential of nurses. We used to think ‘oh, she is just a nurse’. But they can do a lot! And I think that’s our strength here. They will retrieve records and patient files. They will manage the reception. They will dispense. They can do a lot. And I think that’s our strength here’. ART program manager, PNFP-01
To enable nurses broaden and widen their competencies, they were continuously trained through weekly in-house ‘continuing medical education’ on-site trainings to manage an enormous expansion in their traditional scope of practice. Mentorships and on-site support supervision of nurses in HIV care were raised as strategies for unlocking the potential of the nursing workforce. Off-site trainings in HIV care and treatment were cited as another enabler in the expansion of the scope of practice of the nursing workforce at participating health facilities. Several of the off-site trainings were said to funded by donors such as PEPFAR- subsidiaries while others were said to be organized by Uganda’s Ministry of Health.
‘We do a lot of in-house staff development. We know that every Wednesday is a CME (continuing medical education) day. We conduct on-site training for our nurses… many never did presentations but now our nurses do. They can stand up and do presentations, I mean power-point. So we empower them because we don’t pay them that much and when there is an off-site workshop we try to make sure that everyone gets a chance to go to’. ART clinic manager, PNFP-02
Across our interviews with facility in-charges, there was a widely-held perception that nurses were more stable at health facilities compared to cadre with longer post-secondary school training. Physicians were perceived to be mobile on account of their affinity for accepting additional training opportunities and better job offers. As such, nurses were perceived as a cadre that were dependable and could be relied on for long-term planning due to their tendency to remain stable in the same employment and work stations compared to more specialized cadre.
‘We focus on especially nurses because those tend to stick around for years unlike young doctors who frequently opt for further training and leave when better opportunities arise’ Head of clinical services, PNFP-01
Due to the low pay common in public facilities in Uganda, nurses were perceived to be more resilient.
‘We have some cadres who are not easy to work with due to our low wages. For instance, pharmacists, because they have so many (private) pharmacies around which they are supervising and they are crying that the pay is low. So, they always want to get something from outside. So, those ones have been a problem for us but not nurses and midwives. Another cadre is the medical doctors also. They have been a problem to us because most of them were crying of the low salary’ Hospital administrator, PUB-01.
Nurse-led HIV care
Although a number of health facilities indicated that their HIV service delivery was nurse-centred, 38 of the 195 (18%) health facilities in our survey indicated that they adopted nurse-led care models. Under this model, nurses led service delivery along the entire HIV care continuum including in initiating ART. Nurses were trained to have a broad diversity of competencies along the HIV care continuum. The range of tasks assigned to nurse ranged from Tuberculosis (TB) management to counselling of patients as described below:
‘Every nurse here is a dispenser, a counselor, is a triage nurse, she can work in the laboratory and at least can do phlebotomy and at least make an HIV test and work in a treatment room and work in a TB room. so there is a lot of task shifting and multi-tasking so my nurses can do (male medical) circumcision, where I can’t’ ART clinic manager, PUB-04.
Differentiated task-shifting to nurses
In a section of tertiary facilities (e.g. PNFP-01, PUB-02, PUB-03), we found a more differentiated approach to task shifting to nurses. This was in contrast to the practice on some health facilities of devolving clinical management of ART from physicians to nurses.
Stable patients managed by nurses
Patients with advanced HIV disease were reported to be managed by clinician cadre such as clinical officers and physicians while patients who were deemed stable on ART were handled by nurses.
‘The patient numbers are big but we have trained our nurses. Our nurses help us to handle the stable clients. Nurses can help a great deal because patients need to see a doctor at least once or twice a year’ Clinician, PNFP-01
Nurse-led community-based outreaches
Nurses were often assigned to lead HIV care outreach teams into communities. A mission hospital (PNFP-01) within our case-study facilities run a home-based HIV care program for stable patients who live within a 5-kilometre radius of the hospital. Nurses often led typically four-member teams that also comprised ‘expert patients’. They conducted reviews during these home visits and distributed ART refills. The nurse-led community outreach programs were aimed at decongesting overcrowded HIV clinics and easing transport burdens on patients. The nursing workforce was said to critical in these endeavors.