Addressing Human Resources for Health Needs to Support HIV Epidemic Control: Prioritizing Site-Level Interventions in Democratic Republic of the Congo, 2018-2020

Paul Thurman^1,&, Susan Michaels-Strasser², Luc Ferdinand Kamanga Lukusa³, John Ngulefac⁴, Beatrice Lukeni⁵, Serge Matumaini⁶, Lauren Parmley², Sungani Zidana-Ndovi⁷, Faustin Malele⁶

 

¹Columbia University, Mailman School of Public Health, 722 West 168th St., 4th Floor, New York, NY 10032, USA, ²ICAP at Columbia University, 722 West 168th St., 13th Floor, New York, NY 10032, USA, ³Programme National de Lutte Contre le VIH/SIDA (PNLS), Kinshasa, Democratic Republic of the Congo, ⁴United States Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD 20852, USA, ⁵ICAP at Columbia University, Lubumbashi, Democratic Republic of the Congo, ⁶ICAP at Columbia University, Kinshasa, Democratic Republic of the Congo, ⁷ICAP at Columbia University, Lilongwe, Malawi

 

 

^&Corresponding author
Paul W. Thurman, Columbia University, Mailman School of Public Health, 722 West 168th St., 4th Floor, New York, NY 10032, USA. Paul.Thurman@Columbia.edu

 

 

 

 

Democratic Republic of the Congo (DRC) Context and Challenges

 

Democratic Republic of the Congo (DRC) gained independence in 1960, established its current name in 1997, and has received United States President´s Emergency Plan for AIDS Relief (PEPFAR) funding since 2003 [1]. DRC is a country of over 2 million square kilometers that borders seven sub-Saharan African countries. Decades of violent conflict and instability have taken a toll on the country´s economy, and, coupled with a largely rural population, present challenges to providing healthcare [2].

 

DRC has a generalized HIV epidemic with an estimated prevalence of 1.2 percent among adults aged 15 to 49 years. HIV infection is more prevalent in urban (1.6 percent) than rural settings (0.9 percent). An estimated 404,894 people are living with HIV/AIDS, and around 10,535 people die from AIDS-related conditions each year [3]. The HIV/AIDS epidemic has drastically impacted two of DRC´s most populous provinces, with population prevalence estimates of 1.6 percent in Kinshasa and 2.6 percent in Haut Katanga [4].

 

Columbia University´s International Center for AIDS Prevention (ICAP at Columbia University) initiated comprehensive support of HIV/AIDS care and treatment (C&T) services in DRC in 2010. Since then, ICAP has worked with the Programme National de Lutte contre le SIDA (PNLS) to expand the availability, quality, and uptake of adult and pediatric HIV/AIDS C&T in DRC. Emphasis has been on expanding prevention of mother-to-child transmission (PMTCT) activities, development of a laboratory network for disease monitoring, integration of HIV/AIDS and tuberculosis (TB) services, improvement of infrastructure, prevention among key populations (KP) in Kinshasa and Haut Katanga, and epidemic control. In partnership with DRC Ministry of Health (MoH) and donors, ICAP has rapidly expanded its support for PNLS activities from 10 sites in 2010 to 240 public and private hospitals, health centers, and TB clinics in Kinshasa and Haut Katanga as of September 2014. ICAP currently supports over 200 sites in DRC comprising both PEPFAR and non-PEPFAR funded clinics and health facilities. This paper focuses on efforts to improve support for HRH at 16 PEPFAR-identified “high-priority” health facilities (HFs) in Haute Katanga.

 

Human Resources for Health (HRH): Priorities and Challenges

 

Strengthening HRH has been a priority focus of many global public health and epidemic control efforts, especially in African nations [5]. In DRC, numerous training and policy measures have aimed to address gaps in managing a disparate and diverse healthcare workforce, including nurses, community health workers (CHWs), and midwives, across a geographically and culturally diverse country [6]. Since healthcare is often centralized at major health facilities in large cities, decentralized efforts to reach DRC´s largely rural population (often with higher infection rates) are constrained by lack of trained health care workers able to provide full HIV/AIDS services [7]. Further, the abilities of these community staff and HFs to influence local healthcare policies and procedures are constrained by distance, staff burnout, and a sense that rural health services may not “matter” as much [8]. These challenges can lead to staff feeling underappreciated, burned out, or unclear of job responsibilities and expectations [9].

 

For example, in response to the urgent need to increase access to antiretroviral therapy (ART), in close collaboration with the Ministry of Health (MoH) and Nursing Council and Associations, ICAP successfully implemented a PEPFAR-funded program administered by the United States Department of Health Resources and Services Administration (HRSA), the Global Nursing Capacity Building Project (GNCBP), across 10 countries including DRC between 2011 and 2018. HRSA and ICAP partnered with in-country nursing leaders and MOHs and education (MoE) to strengthen the nursing and midwifery workforce.

 

Epidemic Control and PEPFAR

 

In support of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 goals, PEPFAR-supported programs place emphasis on activities proximal to reaching these targets and rapid treatment initiation and clinic and community efforts which focus on retention in care and viral suppression. Therefore, central to our investigations were the staffing levels and activities at 16 PEPFAR-identified “high-priority” HFs in Haut Katanga towards achievement of 95-95-95 goals. PEPFAR identified these sites as “high-priority” ones based on the volume of patients on ART, regional HIV/AIDS prevalence, and the likelihood of good collaborations between local ICAP resources and HRSA/PEPFAR-funded facilities. The HIV/AIDS prevalence in Haut Katanga is 2.5 percent compared to 1.2 percent in Kinshasa and is challenged by a largely rural population and large land mass borders with Zambia (HIV/AIDS prevalence of 11.4 percent among adults aged 15-49) and Malawi (10.0 percent among adults aged 15-49 years) [5,10].

 

Resilient and Responsive Health Systems (RRHS) Projects

 

With PEPFAR funding through HRSA, in 2017, ICAP was awarded the RRHS project to continue strengthening HRH in DRC. Using the World Health Organization (WHO) conceptual framework for HRH development, the first two years of the RRHS project built on extensive HRH capacity building and infrastructure improvements for student nurses and midwives through HRSA funding the Nursing Education Partnership Initiative (NEPI) as a follow-on to the previously funded GNCBP [11]. During 2018-2020, HRSA and ICAP have leveraged these pre-service strengthening efforts to shift focus to in-service capacity building and addressing wider HRH limitations affecting epidemic control. Improving clinic personnel collaboration, implementing healthcare worker and management training in HIV/AIDS, upgrading infrastructure for HRH, and improving morale and job stability via rural rotations of nurse graduates are all examples of RRHS activities that focus on HRH in DRC.

 

The value-added of such HRH interventions extends beyond C&T programs and thus may support faster achievement of PEPFAR 95-95-95 goals. These faster outcomes are well-known from prior research as are the pitfalls if such HRH needs are not addressed [12, 13]. Thus, this paper outlines ICAP´s methods to develop targeted, prioritized, and sequenced interventions–at the HF, MoH, and ICAP levels–to improve HRH effectiveness. With improved HRH effectiveness, ICAP and HRSA hope to demonstrate faster and more efficient achievement of 95-95-95 goals than would have been possible with only C&T interventions, alone [14].

 

 

A needs-driven process was used to determine site-level HRH needs across the PEPFAR-identified 16 high-priority HRs and to develop efficient action plans to address these needs within 12-18 months. This protocol was submitted to the Columbia University Medical Center Institutional Review Board (IRB) and received a “non-research” determination. A series of 13 steps were completed between October 2018 and June 2019 with HRH interventions launched in July 2019:

 

- The PEPFAR Rapid Site-Level Health Workforce Assessment (hereafter, “HRH assessment”) was modified and translated into French [15]. The assessment collected no personal information and focused on challenges that HRH faced, not information regarding daily staffing, etc.

 

- Ten high-priority sites were selected for survey piloting. Local ICAP staff were trained on the survey and then scheduled initial interviews with HF leaders and staff. All participants were advised that no personal information would be logged and that all responses would be anonymous. Any participant could opt-out of the interview at any time

 

- Once the ten pilot site interviews were completed, the ICAP team reviewed findings and suggestions for how to improve the survey

 

- All 16 sites were then interviewed–including re-interviews of the ten pilot sites–with the HRH assessment and presentation of current Monitoring, Evaluation, and Reporting (MER) statistics for each site [16]

 

- The team reviewed all data and prepared summaries of key needs from HF interviews.

 

- The team then assessed patient volumes to determine where excessive patient loads were across the HFs Figure 1

 

- From this work the team developed several hypotheses for interventions that could address key HRH needs. These were discussed with the local C&T teams to determine if any findings were duplicated with C&T efforts

 

- Interventions were then prioritized using a framework with criteria including desirability, feasibility, and time-to-impact [17]. Priorities were shared with key HF and HRSA leaders for review and comment

 

- Interventions were then determined to be of short-term focus (within the first six months), medium-term (in months 7-12), or long-term (in months 13-18, or to be completed by December 2020)

 

- Once agreed, HRH interventions were assigned to be the responsibility of specific sites, all sites, the MoH, or ICAP

 

- Short-term HRH interventions–including establishing a July 2019 baseline of 95-95-95 MER statistics–were launched

 

- Concomitant with short-term intervention launch, a tracking tool was developed comprising both C&T and HRH intervention efforts, that aligned efforts with all 95-95-95 targets

 

- Since mid-2019, monthly reporting of MER data–and of key C&T and HRH intervention progress–has been provided to all in-country leadership and HRSA. Bi-weekly discussions with in-country leaders, ICAP staff, and HRSA leadership are held to assess progress and corrective actions

 

The collaborative process used focused on building trust with sites and empowering HF leaders to express needs for HRH improvement in ways the team could report back to funders and MoH. Trust-building is especially important when providing financial incentives for performance is impossible and quickly adding qualified staff is unlikely [18, 19].

 

The tools developed–and early indicators of HRH effectiveness–would not have been possible without direct, site-level data collection and interviews from HF leaders. By assuring respondents confidentiality of collected inputs, the team was able to obtain honest feedback about key HRH needs. Piloting the process first, and then revising the data collection tool also proved valuable since the team could incorporate learnings from early site interviews to make data collection more effective.

 

Availability of Data and Materials

 

The amended rapid assessment survey used and site-level data collected for this study are available from the corresponding author upon reasonable request.

 

Ethical considerations

 

The Columbia University Irving Medical Center's IRB reviewed this proposed research study and gave it a “non-research” determination (IRB-AAAS2598) on February 22, 2019. This determination was shared with DRC MoH, and the MoH also deemed this study to be of a “non-research” nature. Only site-level information was retained from interviews, and no specific individuals' names or identifying data were captured as part of any interview or discussion. Although none did, any potential interviewee could opt-out of the site-level interview and/or refrain from completing the amended PEPFAR assessment tool in part or in full.

 

 

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. For the most part, HFs in aggregate were well-staffed for HIV/AIDS care.

 

An evaluation of HIV/AIDS caseload was performed to determine if appropriate levels of HIV/AIDS-trained staff were in place at each HF, see Figure 1. While midwives are needed across the board, only four sites (shown in red in the figure) required more HIV/AIDS-qualified health staffing (nurses), and only one site (shown in green) required more doctors and nurses. All others (in blue) were adequately trained and staffed.

 

From these analyses, the team concluded that having enough staff was not a key HRH issue and, instead, other needs likely deserved more attention. The team compiled qualitative results from the HF interviews and derived insights into HRH challenges in the HFs Figure 2

 

— While few barriers seem to be compensation-related, more HIV/AIDS clinical staff and training may be needed. Low morale seems tied to lack of job descriptions, evaluations, and career pathing

 

— Staff and managers noted that improvements in morale may lead to better recruiting and employment at HFs [20]

 

— Community outreach activities are not well-organized, peer educator staffing is not adequate, and no standard documentation for community health workers exists

 

— Work environments require improvement–spaces to collaborate, rest, etc.–and workers constantly request more protective clothing and to join/connect to communities of interest to share and learn best practices

 

— Clinic leaders noted that improved ART distribution would help as would access to more advanced therapies. Budgeting support could also help some HFs according to financial managers [21]

 

 

After careful analysis of HF interview data, the team determined that the barriers, above, could be addressed with hypothesized interventions across the following six domains [22]:

 

Staffing: Increasing clinical hiring and peer educators, and optimizing time allocated to HIV/AIDS patients by these clinical resources

 

Training: Training CHWs in HIV/AIDS-specific care protocols, improving job descriptions and expectations to enhance morale, and enhancing collaboration and management skills

 

Workplace Environment: Providing opportunities for, renovating sites, implementing worker protections, and rewarding community involvement and site leadership

 

Community Outreach: Working to bring more patients into the clinic, increasing screenings, and creating communities of interest to share best practices

 

Medical Supplies and Equipment: Providing access to advanced drugs and equipment, improving supply chains for ART, and helping sites better budget and report 95-95-95 progress

 

Monitoring and Evaluation: Standardizing monthly reviews of 95-95-95 progress and collecting ongoing feedback on barriers to HRH effectiveness [23]

 

Determining responsible stakeholders for these interventions is critical. Four key stakeholders were then assigned responsibilities for interventions across the six domains, above. Interventions would be implemented by all sites, selected sites, the MoH, and/or by ICAP.

 

However, not any/every intervention is of the same urgency nor could all hypothesized ones be launched simultaneously. Thus, the team constructed a set of prioritization criteria in order to stage and sequence these interventions in a more manageable way [24]:

 

Desirability: Do HFs, MoH, ICAP really want to pursue this intervention (based on past experience, etc.)?

 

Feasibility: If the intervention is desirable, do HFs, MoH, ICAP, etc. have the resources, skills, and tools ready to kick-off the intervention?

 

Viability: If stakeholders have the skills and time, do they have the funding, or can they quickly get it to fund the intervention?

 

Sustainability: Once implemented, will the HRH interventions stand the test of time or be lost as one-time changes?

 

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. 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). Two short-term interventions had already been initiated by C&T teams Figure 3.

 

Based on successes of similar HRH interventions in other sub-Saharan contexts, the team expects to see several improvements [23]. These are aligned with the major HRH domains mentioned previously:

 

Staffing: Increase numbers of patients tested for HIV/AIDS and those treated if positive as more qualified health workers, midwives, and peer educators are put into the HRH workforce

 

Training: Install more staff able to help HIV/AIDS patients, improve satisfaction, and enhance clinic leadership. These should create more awareness for clinics for new and existing cases

 

Workplace Environment: Improve workplace environments that lead to more team-based care, best practice implementations, and improved morale for staff

 

Community Outreach: Create wider networks in the community and build trust with clinics. This will increase treated cases, follow-ups, lower viral loads, etc.

 

Medical Supplies and Equipment: Deploy therapies to patients more quickly and give workers more security via enhanced protective equipment

 

Monitoring and Evaluation: Place emphasis on achievement of 95-95-95 goals with standard reporting across clinics to implement best practices

 

To track these expected improvements, a comprehensive reporting system that incorporates both monthly MER data, to track C&T improvements, and the HF interventions noted earlier, was developed. In this way, all stakeholders were able to view monthly progress updates, note where efforts are not meeting desired goals, and see corrective actions being taken to address shortcomings Figure 4.

 

The team hopes to use these data to perform future 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.

 

Sustained contact with stakeholders throughout the processes of setting MER baselines and HRH staffing, hypothesizing possible interventions, prioritizing interventions, and launching and tracking implementations allowed the team to keep them aligned and focused on important endpoints. Stakeholders agreed to the major domains of HRH needs, prioritization criteria, and the staged implementation plans. Since launch, stakeholders have appreciated the value of monthly MER reporting aligned with updates that show successes and challenges.

 

Keeping focus on various stakeholder needs has proven to be valuable as MoH priorities may not always align with HF needs. This, in turn, has built trust across several constituents, all of whom have a vested interest in HIV/AIDS epidemic control through improved HRH staffing, training, and collaboration. But without tracking–of both intervention progress and the direct results of interventions through MER results–any program will likely produce suboptimal or unmeasurable results.

 

Limitations

 

Some limitations to this approach are noteworthy. First, only PEPFAR high-priority HFs were interviewed for these targeted HRH interventions. Although the team believes these interventions are relevant to other HFs, the HRH assessment did not compare priority to non-priority sites and has not identified possible divergent HRH needs.

 

Secondly, given different country contexts in which these interventions may apply, results may vary based on MoH adoption, in-country and external funding, and in-country HRH staffing and skills. The team hopes to pilot this study elsewhere to see if other HFs identify similar HRH needs and can realize similar gains from such interventions.

 

 

While the correlation between number of health workers and care outcomes is well documented [25], less evidence exists regarding HRH interventions that go beyond the staffing numbers. Here, the team determined that some HRH needs and challenges, for 16 high-priority PEPFAR HFs in DRC, were not related to staffing levels but to other factors including training, workplace environment, morale, and a need to be connected to other HFs and best practices.

 

Staffing levels did not appear to be a significant HRH challenge–except for certain needs in certain sites. Getting staff properly trained, connected to each other, and aligned with formal job descriptions could yield significant benefits as measured by MER target achievement and staff morale. Keeping staff trained, on task, and connected appear to be significant drivers of positive culture and therefore help staff work better, together, to improve testing, treatment, and follow-up for those with HIV/AIDS. The team hopes to pilot similar efforts at non-PEPFAR sites, both within DRC and in other countries, and report successes that could not have been achieved with C&T initiatives, alone [26]. Success of these HRH interventions, then, should be linked to national and regional health policies, and HRH effectiveness can be more of an enabler than a constraint of epidemic control [27].

 

 

The authors declare no competing interests.

 

Funding

 

Funding for this effort was provided to ICAP at Columbia University through HRSA grant UH6HA30739. John Ngulefac, one of the study's co-authors, is Public Health Analyst, HRSA, and has supervised this funding.

 

Consent for Publication

 

The views expressed in this article are those of the authors and should not be construed to represent the positions of HRSA or of the organizations with which the authors are affiliated.

 

 

PT developed the overall research methodology including interview guides, prioritization frameworks, and intervention plans. SM-S provided background on the PEPFAR, DRC, and HRH contexts and developed a reporting framework for site-level interventions. JN and LFKL contributed to the in-country implementation funding and prioritization. BL and SM provided in-country technical guidance and RRHS leadership (including site-level collaborations). LP provided all strategic information reporting and tracking including MER indicators and site-level intervention evaluation. SZ provided project coordination and communication across New York, Kinshasa, and Lubumbashi teams, and FM provided overall country leadership including ICAP-MoH collaborations and approvals. All authors read and approved the manuscript.

 

 

The authors wish to thank all study respondents, MoH, PNLS, HRSA, and ICAP leadership and staff for their time and ongoing commitment to HIV/AIDS epidemic control in DRC. The authors also thank Stella M. Lodewick, Glen Ridge High School, Glen Ridge, New Jersey, USA, for her assistance with background research on intervention policy and implementation and for her help organizing our bibliography and citations.

 

 

Figure 1: HIV/AIDS Case Load for High-Priority HFs (as of March 2019)

Figure 2: Major Challenges to Meeting PEPFAR Targets (Across All High-Priority HFs): March 2019

Figure 3: Short-Term Interventions (All Domains) for High-Priority HFs, MoH, and ICAP, May 2019

Figure 4: Site-Level Intervention Tracking Tool (Through November 2019) - MER Indicators and Progress, Only

 

 

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