In terms of supply-side structural inputs and processes supporting HIV testing and
counselling in routine antenatal care provided at health centers, we first review
results regarding space or physical infrastructure and the availability of supplies
(drugs and equipment). We then describe issues related to staffing, including health
worker respondent characteristics and their availability. We also detail their provision
of services, including their knowledge and delivery of HIV counselling messages during
antenatal care. We conclude with results that further describe the context and content
of HIV counselling during antenatal care to provide a more complete understanding
of supply-side elements of delivering such services.
Infrastructure
Just over half of the health centers had a complete composite score taking into consideration
four domains: 1) presence of HIV diagnostic and treatment services, 2) availability
of waiting and registration area, 3) availability of counselling area, and 4) availability
of furniture (Fig. 1). Spacing was judged based on the availability of any space, not the extent of the
space. Variations in infrastructural deficiencies among health centers did not differ
significantly by groupings of urban, suburban, and rural health centers. Two outlier
health centers (one designated as rural and one designated as suburban) with the lowest
composite scores were both undergoing upgrading from dispensaries to health centers
at the time of data collection.
Fig. 1. Availability of Infrastructure. The health infrastructure composite scores include
a) HIV diagnostic and treatment services (laboratory, presence of CTC); b) waiting and registration area (waiting area, covered or roofed waiting area, well-ventilated
registration/waiting area); c) counselling area (dividing curtain or screen, well-ventilated group counselling
area, and sufficient space for pregnant women to walk); d) furniture (at least one desk and at least one chair for provider, at least one chair
for patient; sufficient chairs and space for one companion of each patient)
Of the health centers with deficiencies, three facilities lacked either a laboratory
or a CTC, or both. One health center did not have a well-ventilated waiting/registration
area or group counselling area. While all health centers had a well-ventilated group
sitting area, researchers observed that two health centers did not have sufficient
open space in which pregnant women could walk while waiting for routine antenatal
services. While all health centers had at least one chair for women, eight health
centers lacked a desk for providers and one health center in addition lacked at least
one chair for providers.
For just over half of the health centers, space was estimated to be sufficient based
on the composite indicators of availability mentioned above; however, the research
team observed crowded waiting areas at most health centers. In addition, health workers
commented on the lack of space to provide private and confidential services to HIV-positive
pregnant women (Provider 04–12, enrolled nurse). Provider 07–09, an enrolled nurse,
said:
The room is too small… It’s hard to give counselling here, share results, and you
have to come inside… It would have been better if we had a big room, with space for
HIV, PMTCT counselling, space for testing… [A patient] can come and find [the] place
is full of people.
Supplies
In Tanzania, the Medical Stores Department (MSD), a semiautonomous organization under
the MoHSW, procures and distributes all equipment and supplies 35]. At the time of research, facility in-charges order the supplies and equipment each
month based on projections from previous months. The MSD then orders and distributes
supplies by zone. For Morogoro, the supplies are ordered and come from the Coastal
zone located in Dar es Salaam. At the time that the research team was collecting data,
the zonal MSD took supplies to the District Medical Officer (DMO), who distributed
the drugs and supplies to health facilities according to the requisition orders from
each facility. Today, drugs, including HIV drugs, are ordered on a quarterly basis,
and zonal MSD take drugs either directly to the health facility or to the DMO. Initial
funds for HIV drugs are provided by external donors, and the MSD handles distribution
of the drugs throughout Tanzania.
At the time of the research team’s visit, six (33 %) health centers could not undertake
HIV testing. One health center attributed this to the lack of equipment such as gloves,
while the other five attributed this to the lack of supplies such as HIV test kits.
In addition to test kits, there was also a shortage of some types of drugs for HIV
and PMTCT. Of the six drugs on the facility assessment checklist, single dose nevirapine
(sdNVP) for the mother had the most unreliable supply: seven out of the 18 (39 %)
health centers did not have a continuous supply in the 30 days preceding the research
team’s visit. One health center reported that the drug had been out of stock for six
months. Five health centers reported zidovudine (AZT) and lamivudine (3TC) out of
stock and four reported lack of nevirapine syrup for children (Fig. 2). Variations in levels of HIV drug supplies and equipment did not differ by the location
of the health center in urban, suburban, or rural settings. One outlier facility in
a rural area had the lowest levels of stock for all three categories included under
supplies: HIV drugs (four out of five was out of stock), infection prevention supplies
(seven out of 14 were unavailable), and infection prevention equipment (nine out of
11 were not present). The low levels of supplies at this facility can be attributed
to its recent upgrade from a dispensary to a health center at the time of the research
team’s visit.
Fig. 2. Availability of functional essential supplies and equipment for delivery of integrated
HIV/ANC services
In coping with these shortages, pregnant mothers at one health center were asked to
bring gloves, typically during labor and delivery, to prevent the possibility of infection:
I do not want to infect you or for you to infect me either. (Provider 07–09, enrolled nurse)
Apart from increasing the burden of seeking services on women, health workers noted
with frustration that the lack of supplies also led to missed opportunities:
It’s just that missing supplies made these people not able to return …you know…when
you give someone [services], you are supposed to test her immediately… If you delay, she might slip [out of the health system]. (Provider 18–08, registered nurse)
Women had varying responses to missing supplies. One provider discussed women’s reactions
to arriving at the health center and finding that the HIV test could not be performed
due to stock-outs as thus:
Some women keep on reminding [their providers during subsequent antenatal visits] that they didn’t take an HIV test during the first visit at the clinic because there
were no facilities…for those [women] who didn’t like to test, they intentionally take advantage. (Provider 07–06, enrolled nurse)
In addition to missed opportunities to engage with pregnant women and provide HIV
counselling, providers also saw the lack of supplies as undercutting their relationship
with their patients and the reputation of health centers in the community. HIV test
kit stock-outs were described as an “embarrassmentâ€, and that:
Some [women] ask us why others did not get tested and we did? So it’s true everything we do here
gets back to the community. (Provider 02–27, enrolled nurse)
Staffing
Characteristics of health worker respondents
The mean age of antenatal providers interviewed was 39 years, and 78 % were women.
Almost half of the providers were married or co-habiting; 38 % were single; and the
remaining 11 % were widowed, divorced, or separated. They worked a mean of 14 years
as a health worker, including 6 years at the health center where the interview was
conducted (Table 5). Although 71 % were enrolled and registered nurses, 15 % were medical assistants
and 3.1 % were health assistants. According to guidelines, neither medical nor health
assistants are qualified to provide antenatal care.
Table 5. Characteristics of antenatal care providers interviewed (N = 65)
Availability and distribution of staffing
Providers commented on the lack of human resources at health centers, with some attributing
increased queues for integrated antenatal services to the insufficient number of health
workers. The average number of health care workers per health center was 24, with
approximately 11 providing RCH services. Of those providing RCH services, 36 % were
absent on the day the research team visited the health center due to annual or sick
leave, training, work trips, or travelling to collect their salaries. While health
centers in suburban and rural settings on average met MoHSW recommended staffing levels
for most cadres, the urban health center exceeded the recommended staffing level for
assistant medical officers, clinical officers, and enrolled nurses (Table 3). Yet when considering the larger population this urban health center needed to cover,
it had on average lower levels of staffing per population size than several rural
health centers.
Human resource challenges led some health centers to designate one day each week as
the day for HIV testing and counselling, which separated HIV testing and counselling
from routine RCH services with implications for access to services and stigma.
The shortage of facility health care providers … [the woman] has come today expecting that she is going to finish everything, then you are telling
her of the other day [for the HIV test], she may not come… there are others who don’t come back. (Provider 05–03, registered nurse)
As a result of integration, health workers were expected to perform additional tasks
related to HIV testing and counselling during antenatal services (Table 2). If HIV testing couldn’t be performed at the first antenatal visit or if the test
result were positive, providers had additional follow up tasks to perform after the
antenatal visit. Health workers reported that the increased workload, lack of sufficient
providers, and lack of integration of care and treatment were demotivating.
More than 60 [women] in a single day, and you are only two… it discourages a lot, when you find [a] positive [test result], you have to take her direct to CTC and ask them to attend her so that you can continue
with others. What we want is all services of the [HIV] positive [women] to be done at RCH. (Provider 02–27, enrolled nurse)
Provision of HIV counselling
At least two-thirds of health workers providing antenatal care recalled all specific
modes of HIV transmission and three out of four ways of preventing HIV transmission.
However, each mode of HIV transmission was mentioned in at most 10 % of observed individual
antenatal sessions (20 out of 203 sessions, Fig. 3). Similarly, while 72 % or more of providers (47 or more out of 65 providers) could
recall messages related to HIV testing without prompting, providers at only 11 % of
individual counselling sessions (22 out of 203 sessions) were observed to have asked
women whether they knew their HIV status, 26 % (53 out of 203 sessions) encouraged
women to get tested for HIV, and 23 % (47 out of 203 sessions) gave information about
where to access HIV testing services. Providers at just under a fifth (18 %, 36 out
of 203) of antenatal counselling sessions were observed to have used job aides such
as notes (Table 6). The MoHSW provides FANC job aides to all health centers providing antenatal care
and PMTCT job aides to health centers where PMTCT services are available, to be used
by providers who had received PMTCT training.
Fig. 3. ANC provider knowledge and percent of observed counselling sessions with delivery
of HIV- and ANC-related messages
Table 6. Observed characteristics of ANC counselling sessions (N = 203)
Analysis of the duration and content of antenatal counselling showed that providers
had limited time with each patient (Table 6). Group counselling sessions covered a range of topics, including maternal health
during pregnancy and after birth, antenatal care, newborn care, HIV/AIDS, and malaria.
These group counselling sessions lasted a median of 15 minutes, ranging from 10 to
33 minutes. Individual counselling and clinical sessions lasted a median of 12 minutes,
ranging from 2 to 66 minutes. The ranges in the length of time for counselling sessions,
whether for group or individual counselling, suggested that despite FANC and PMTCT
guidelines, substantial variability existed in counselling content. Health providers
and patients indicated that the short time spent with each patient and long wait times
for services were due to the lack of RCH providers (Table 6).