Task shifting or shifting care practices? The impact of task shifting on patients’ experiences and health care arrangements in Swaziland

Abstract

BackgroundIn the quest to achieve early HIV treatment goals, national HIV treatment programmes dependent on international funding have been dramatically redesigned over the last 5 years. Bottlenecks in treatment provision are conceived of as health system problems to be addressed via structural and logistical fixes (routine HIV testing, point-of-care equipment, nurse-led antiretroviral treatment initiation, and patient tracking). Patient perspectives are rarely taken into account when such fixes are being considered. Patients’ therapeutic experiences often remain at the periphery during the planning stage and are only considered within the context of monitoring and evaluation audits once programmes are up and running.MethodsEthnographic research was conducted in five clinics in Swaziland between 2012 and 2014. Participatory approaches were used to collect data; the first author trained as an HIV counsellor in order to collect observational data on the continuum of care, and conducted in-depth interviews with interlocutors involved at the different phases.ResultsAlthough recently adopted global HIV strategies have proven effective in scaling up treatment in Swaziland, our research demonstrates that the effort to expand services rapidly and to meet donor targets has also undermined patients’ therapeutic experiences and overtaxed health workers, both of which are counterproductive to the ultimate goal of treatment scale-up. This article provides a perspective beyond the structural elements that impede universal treatment, and explores patient views and experiences of the strategies adopted to support further treatment expansion, with a particular focus on the shifting of key care and logistical tasks to expert clients.ConclusionWe argue that in the quest to achieve universal early access to treatment, both donors and states must go beyond strengthening health systems and strive to enhance the quality of patient experiences and take seriously health worker limitations.

Patient satisfaction with directly observed treatment and multidrug-resistant tuberculosis injection administration by lay health workers in rural Eswatini

“…In addition, PHC facilities are often distant and geographically inaccessible from patients' homes and are also frequently characterised by lack of front-line TB human resources for health (HRH). 11,12,13,14 In this context, front-line TB HRH refers to healthcare workers who are generally the community's first level of contact within a PHC system for accessing TB services. To address the prevailing MDR-TB treatment access and HRH challenges in the predominantly rural Shiselweni region, in 2008, Médecins Sans Frontières (MSF) established a novel patient-centred community-based MDR-TB treatment strategy based on taskshifting within the existing NTCP.…”

Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study

“…The establishment of basic care standards must also recognize that provider burnout can be significant in systems wherein lesser trained individuals are given additional tasks, especially as care is scaled and providers may be taking on more and unfamiliar tasks. [32] The iterative development of achievable standards and competencies as tasks are shared with non-specialist providers, adapted over time as the task shared mental health system matures, may be the most appropriate solution. This is especially important as the mental health services available at health centers are expanded to include the delivery of formal psychotherapies designed for delivery by non-specialist providers.…”

Roles and Responsibilities of Expert Clients in Adolescent HIV Service Delivery in Eswatini: A Conventional Content Analysis

“…As task shifting begins to expand the skillset and scope of practice among ECs, it is important to consider strategies to assuage their work burden. Dlamini-Simelane and Moyer's (2017) ethnographic study con rms that while ECs have been able to take on more clinical responsibilities, the quality of care has not improved (36). Therefore, there is a need to consider robust strategic planning around coordinating responsibilities among professionally trained clinicians and lay personnel to avoid burnout and fragmented service provision that may inadvertently lead to ine cient time and costs spent on HIV service delivery.…”