Perception _study_Shiselweni_FINAL_2013_05_22 (1)

Evaluation of the decentralisation strategy
for HIV/TB care and task shifting in
Shiselweni, Swaziland
Perception and acceptability
Study report
March 2013
Principal investigator:
Mzia Turashvili
Co-investigators:
Heidi Becher, Sarah Lachat,
Mfanawenkhosi Maseko, Siphiwe Ngweny
MANAGED BY THE VIENNA EVALUATION UNIT

Acknowledgements
We would like to thank all individuals, patients, community members, health staff,
representatives of MOH, MSF, HIV/TB partner agencies and civil society organisations who
graciously gave their time for interviews and openly shared their thoughts, ideas and
recommendations.
Particular thanks go to the Mbabane and Nhlangano MSF-OCG teams for their support,
their interest and the fruitful collaboration, to the Nhlangano MSF-PSEC team for helping
to organise the interviews at community level, to the interpreters and the interview
transcription team for their important contribution to this study.

Table of contents
Acknowledgements ................................................................................................................. 2
Table of contents..................................................................................................................... 3
Executive summary.................................................................................................................. 5
Abbreviations........................................................................................................................... 9
1 Introduction.................................................................................................................... 10
1.1 Background.............................................................................................................. 10
1.1.1 HIV/TB situation in Swaziland...................................................................... 10
1.1.2 Overview of the implementation ................................................................ 11
1.1.3 Rationale for the study................................................................................ 13
1.1.4 Objectives of the perception study............................................................. 14
1.2 Methodology........................................................................................................... 14
1.2.1 Study setting and population ...................................................................... 14
1.2.2 Study design and sampling.......................................................................... 15
1.2.3 Data collection............................................................................................. 15
1.2.4 Data analysis................................................................................................ 16
1.3 Limitations............................................................................................................... 16
2 Findings........................................................................................................................... 18
2.1 Perception of objectives and role of task shifting................................................... 18
2.2 Implementation process ......................................................................................... 18
2.2.1 Human resources and task shifting............................................................. 19
2.2.2 Infrastructure strengthening....................................................................... 30
2.2.3 Laboratory support...................................................................................... 30
2.2.4 Drugs and other commodities supply ......................................................... 31
2.2.5 Programme monitoring............................................................................... 32
2.2.6 Community-based activities........................................................................ 32
2.3 Programme outcomes and impact.......................................................................... 34
2.3.1 Accessibility of HIV/TB care......................................................................... 35
2.3.2 Changes in quality of care ........................................................................... 39
2.3.3 Prevention ................................................................................................... 40
2.3.4 Treatment outcomes................................................................................... 41
2.3.5 Coverage...................................................................................................... 42
2.4 Societal factors – determinants of uptake.............................................................. 44

2.4.1 Stigma – discrimination – disclosure........................................................... 46
2.5 Strategic approach – successes and challenges...................................................... 47
2.5.1 Patient involvement and empowerment.................................................... 48
2.5.2 Speed of decentralisation roll-out............................................................... 48
2.5.3 Coordination with other HIV/TB actors....................................................... 50
2.5.4 Advocacy...................................................................................................... 51
2.5.5 Focus on clinics versus mother health facilities.......................................... 52
2.6 Future perspectives................................................................................................. 52
2.6.1 Programmatic perspectives......................................................................... 52
2.6.2 Health policies ............................................................................................. 54
2.7 Sustainability ........................................................................................................... 54
3 Conclusion and discussion.............................................................................................. 57
4 Recommendations.......................................................................................................... 63
5 Annex.............................................................................................................................. 65
5.1 Maps of Shiselweni region ...................................................................................... 65
5.2 Selection of study participants................................................................................ 66
5.3 Interview guides...................................................................................................... 67
5.4 List of interviewees ................................................................................................. 72
5.5 Glossary of quotes................................................................................................... 78
5.6 References............................................................................................................... 79
The Vienna Evaluation Unit
The Vienna Evaluation unit started its work in 2005, aiming to contribute to learning and accountability in
MSF through good quality evaluations. The unit manages different types of evaluations and learning
exercises and organises training workshops for evaluators.
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Evaluation of decentralisation strategy for HIV/TB care and task shifting in Shiselweni, Swaziland: Perception and acceptability, 2012
5
Executive summary
Background
Since the end of 2007 MSF-OCG has been supporting the Ministry of Health (MOH) in
Swaziland to decentralise HIV and TB care in Shiselweni region in order to increase access
and coverage in this high prevalence context. Treatment and care were gradually
decentralised to all the 22 existing primary health care clinics. A holistic approach at clinic
level included health promotion, mobile HIV testing and counselling, TB screening,
defaulter tracing as well as MDR-TB home care up to community level. Task shifting was a
major strategy.
After five years of roll-out, this qualitative study was commissioned with the objective to
explore the different stakeholders’ perceptions on the process and the achievements. The
accessibility of services, acceptability of new strategies and perceived perspectives of the
programme were also explored.
Methodology
A detailed protocol was developed to describe qualitative research methods and purposive
sampling for this study which was approved by the ethics review boards of Swaziland and
MSF. Between November 2012 and February 2013, a total of 118 sessions were conducted:
105 individual interviews, five group-interviews (of two people) and eight focus group
discussions. Respondents included health workers, patients, community leaders, MOH,
MSF and other national and international actors. Study sites covered six clinics and one
central health facility and their surrounding communities. The study employed a
framework analysis approach. Interview transcripts were coded in Nvivo software and
categories were built to frame the main findings. Triangulation of findings from different
sources of information was used for validation.
Main limitations of the study comprise the following: field researchers might have been
perceived as being close to MSF and creating response bias; selecting patients at health
facilities and from existing support groups may have biased the findings on patient
perception towards those who are more satisfied with the services; translation of
interviews might not always have captured the exact meaning. Time and budget limited
the number of verbatim transcriptions. In terms of the interpretation of findings of
Hlatikulu hospital it must be taken into consideration that this hospital has received much
less support from MSF for ART services than primary health care clinics.
Main findings and conclusions
The study highlighted the different components that were essential to achieve a successful
decentralisation of HIV and TB care to primary health care level, namely 1) covering the
human resource gap by additional staff and task shifting, 2) involving people leaving with
HIV/AIDS in health-care provision, 3) improving infrastructure, 4) decentralising laboratory
and implementing effective sample transport, 5) providing an uninterrupted drug and
commodities supply, 6) ensuring an effective programme monitoring and supervision
system and 7) introducing community-based activities to assure acceptance of services and
further decentralisation of diagnosis and care.

6
Task shifting is now widely accepted as feasible and indispensable for the decentralisation
of HIV/TB care in Swaziland, a country with limited human resources for health. Initial
resistance was overcome by demonstration of its feasibility and impact. Advocacy in
alliance with other implementing partners was instrumental. This led to the development
of a national task shifting framework, a crucial policy document.
The combination of formal staff training with mentoring and supervision brought good
results which were highly appreciated. Government certified training courses increased
acceptance and are needed to enable future absorption of the new cadres. Having
completed secondary level of education increases new (lay) health workers’ ability to
follow more complex training; it also improves their chances of formal recognition and
future absorption by MOH.
Health workers feel empowered. Their motivation and work satisfaction are very high.
Interdisciplinary team relationship after decentralisation and integration of HIV/TB services
accompanied by task shifting is largely perceived as positive. Former lay cadres are now
seen as specialists in their area. Professionalisation has led to demands for career
development and better remuneration. Expert clients who work as counsellors are
perceived as being underpaid although crucial in their role. A policy document on task
shifting that reflects newly acquainted roles and tasks of health cadres is developed in
Swaziland but is not officially endorsed.
Staff health care and TB infection control at the work place, as provided by MSF, is
highlighted as very important and relevant in this context of high HIV prevalence among
staff, as is prevention of counsellor burnout.
Decentralisation has substantially increased the accessibility of HIV and TB services. Having
services available at clinics reduced distance and transport cost and is highly appreciated
by respondents. However, people living in very remote areas still have to cope with access
difficulties. Overall the acceptability of HIV/TB services at clinic level is very high. Quality of
care is perceived as very good at clinics and as mixed at central facilities. Waiting time at
clinics is now less than it used to be at central facilities before decentralisation. It also
significantly decreased overtime at central health facilities. Integration of HIV/TB care into
primary health care has increased the level of privacy at the clinics. This is not the case at
central health facilities where HIV care is provided at special ART clinics. Small user fees at
clinics are not an obstacle. Higher fees at central level or private clinics charged for non-
ARV/TB care and medicines still seem to deter some patients. When it comes to choosing a
health facility, convenience (shorter distance and lower travel cost) seems to be the
number one determinant for most patients. The fear of being recognised by community
members at the local clinic or the perception of better quality of care at another place, are
reasons for a smaller number of patients to select a more distant facility.
There is a general agreement that decentralisation and the integration of HIV/TB care into
primary health care has had a positive impact on the quality of care. Similarly informants
agree that decentralisation has substantially contributed to increased coverage of early
diagnosis and treatment, improved treatment outcomes and enabled better retention in
HIV care since distance and travel and time costs were major barriers for accessing care.
The coverage among men, however, is low. Study participants concluded that the
decentralisation of HIV/TB services also positively impacted on prevention by improved TB
control, prevention of mother-to-child transmission services, HIV testing and condom

7
availability. Challenges for prevention were low diagnostic uptake among men, insufficient
acceptance of lifelong ART by eligible pregnant women and consistent use of condoms.
HIV and TB related stigma, gender norms, traditional beliefs and practices all influence the
population’s health seeking behaviour.
While stigma and discrimination related to HIV/TB is widely said to have substantially
reduced over the past years – due to improved knowledge and availability of ART – it is still
seen as a major barrier for early diagnosis, treatment and retention in HIV care, but also for
prevention. The fear of stigmatisation and self-stigma hinder disclosure and consequently
reduce the use of condoms and the uptake of lifelong ARV treatment by pregnant women.
Community leaders are highly respected and influential. Involving them in all community-
based HIV/TB activities is therefore perceived as a very relevant strategy to increase
acceptance.
Whereas differences in gender norms and use of maternity care make it easier to reach
women at health facilities, expectations on the male gender discourage early health
seeking behaviour in the modern health sector. This seems to be compounded by men’s
stronger fear of HIV related stigmatisation and the perceptions of clinics being not male-
friendly enough. Men and youths are seen as groups of society that are hard to reach.
Traditional medicine remains the first choice and is used in parallel to modern treatment
by many patients despite increased community knowledge and availability of HIV/TB
services.
Different opinions were expressed about MSF’s high speed of implementing programme
activities and for its hands-on approach. On the one side, it is perceived that MSF’s rapid
roll-out of decentralisation has largely benefited patients and contributed to the
demonstration of the feasibility of new strategies and higher standards of care. Many
participants concluded that less would have been achieved, if MSF had not increased the
speed of implementing. On the other hand, MSF was initially perceived by MOH as using an
emergency approach that was inappropriate for chronic disease control. This perception
and the lack of joint planning at regional level led to initial resistance. It allegedly delayed
the development of a more productive early collaboration between MOH and MSF. In
addition, MSF’s decision to implement certain activities in parallel to the MOH system is
seen as having negative impact on MOH ownership and sustainability. It was, however,
positively remarked that a shift in MSF’s collaboration with MOH towards much more
dialogue and integration resulted in a more fruitful partnership. Besides, it seems that the
impressive results of decentralisation have also made MOH more receptive for MSF
proposed strategies. Thus, MSF has acted as a catalyser for change not only at field but also
at policy level.
Mixed opinions were also expressed in relation to MSF’s approach of advocating for
change and innovation and for patients’ right to treatment. While the demonstration of
feasibility of innovations by piloting or operational research and proactive dialogue were
seen as very powerful tools, speaking out about shortcomings of the national drug
procurement system, together with civil society organisations, was perceived by MOH as
inappropriate. Some partner organisations of MOH and civil society organisations,
however, seem to be eager to see proactive and outspoken MSF.

8
Involving patients as expert clients is seen as a major key for success of acceptability of HIV
testing and treatment, adherence and patient empowerment. They encourage disclosure
and stigma reduction and are role-models in the community.
Community-based activities were similarly highlighted as a particular strength of the
Shiselweni model.
The findings of this qualitative study do not reveal discrepancies in perceived performance
between the clinics that were selected as the ‘best’ and the ‘worst’ performing clinics.
MSF’s choice to focus support on clinic level seems to have been justified given the huge
unmet needs in terms of access to HIV/TB care in the periphery. However, study findings
suggest that central health facilities have been lacking some support with the consequence
that they now seem to fall behind the clinics in some aspects.
Despite the fact that some important preconditions for sustainability are met – among
them the political will to sustain the basic decentralised HIV/TB care model, the capacity
building of staff and effective laboratory support – great fear is expressed that quality of
care could drop and some systems could collapse once MSF’s support ended. The major
barrier for sustainability identified is the lack of funding, namely funding of human
resources but also for laboratory reagents, sample transport, drug supply and supervision
that are supported by MSF. MSF’s persisting leadership in the regional programme
implementation is perceived as another barrier to greater MOH ownership.
The priorities highlighted for future scale-up of HIV and TB care include 1) PMTCT B+
followed by ‘Test and Treat’, 2) community-based ARV distribution and 3) development of
more male-friendly strategies. Regarding community-based ARV distribution, doubts were
expressed about the suitability of ART group models from neighbouring countries. On the
policy side, the main priorities mentioned comprise the official recognition and
implementation of the task shifting framework, testing policies for minors that allow HIV
testing without parents’ consent and routing HIV testing at health facilities as well as the
legalisation of TB home injections by lay community treatment supporters.
The findings of this study suggest some particular strengths of the Shiselweni model that
may be interesting for replication: nurse-led ART and TB care at all health facilities and
well-organised task shifting to new cadres; a strong community component, ensuring the
link between health facilities and the community; strong patient support, education and
counselling by expert clients; strong HIV and TB integration with a relevant focus on (MDR)
TB; decentralisation of laboratories by installing mini-laboratories at clinics and ensuring
sample transportation to upgraded reference laboratories; piloting of innovations and
operational research.
For recommendations, please see chapter 4.

9
Abbreviations
ART antiretroviral treatment
ARV antiretrovirals
AZT zidovudine
CHAI Clinton Health Access Initiative
CDC Centers for Disease Control and Prevention
DOT daily observed treatment
DR-TB drug-resistant TB
DS-TB drug-sensitive TB
EC expert client
EGPAF Elizabeth Glaser Paediatric AIDS Foundation
HIV human immunodeficiency virus
HTC HIV testing and counselling / HIV testers and counsellors
IMAI Integrated Management of Adolescent and Adult Illnesses
IMF International Monetary Fund
IPT isoniazid preventive therapy
MDR-TB multi-drug resistant TB
MOH Ministry of Health and Social Welfare
MSF Médecins sans Frontières
NARTIS nurse-led ART initiation
NGO non-governmental organisation
OCG Operational Centre Geneva
OI opportunistic infections
PEPFAR US President Emergency Programme for AIDS Relief
PLWHA People Living With HIV/AIDS
PMTCT prevention of mother-to-child transmission
PSEC patient support, education and counselling
TB tuberculosis
VCT voluntary counselling and testing
WHO World Health Organization

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1 Introduction
This report describes the findings of a qualitative study on the perception of the
decentralisation strategy of HIV/TB care and task shifting in Shiselweni region, Swaziland. It
has been implemented with the support of Médecins sans Frontières (MSF) Operational
Centre Geneva (OCG) in partnership with the Swazi Ministry of Health and Social Welfare
(MOH) since the end of 2007.
1.1 Background
1.1.1 HIV/TB situation in Swaziland
The Kingdom of Swaziland is a South African country, which shares borders with the
Republic of South Africa in the North, West and South and with the Republic of
Mozambique in the East. The country extends over a landmass of 17 364 square kilometres
and is considered the smallest country in the southern hemisphere.
Despite being considered as a middle income country the majority of the population 1
live
below the poverty threshold. More importantly, Swaziland is the seventh most unequal
country in the world, the income share held by the poorest 20% is only 4.4%2
.
In line with the economic growth in the past decades, the health situation of the Swazi
population has improved significantly during the eighties and early nineties. However,
Swaziland is currently facing dramatic HIV/AIDS and tuberculosis (TB) epidemics negatively
impacting on the socio-economic development, health and mortality of its population and
resulting in reduction of live expectancy to 40.2 years by 20083
.
HIV prevalence in Swaziland is the highest in the world with 26% among adults (15-49 years
old).4
The country also has a high estimated HIV incidence rate (3%) compared to other
countries in the region5
.
Linked to the catastrophic HIV/AIDS epidemic, Swaziland has been facing a dramatic six-
fold increase of TB cases notification in the last 15 years. TB notification and the estimated
TB incidence rates are now the highest in the world (ahead of Djibouti and South Africa).
Drug-resistant TB (DR-TB) is a consistent threat to the country’s population and even more
to the HIV positive population – an indication supported by the results of the Drug
1
69 percent of the population are poor (live below the upper poverty line - in the lowest 40 percent of the
per adult equivalent national consumption distribution) and 37 % live in extreme poverty (the core poor are
people ranked in the lowest 20 percentof the distribution); see SDHS, 2008.
2
IFAD, 2012.
3
UNDP. Human development statistical update. 2008 year.
Prior to the demographic impact of the AIDS epidemic, life expectancy at birth has improved significantly
from 44 years in 1966 to 60 years by 1997 with females (63 years) living slightly longer than males (58 years).
4
Central Bureau of Statistics and Marco International Inc. Swaziland Demographic and Health Survey 2006-
2007. Mbabane, Swaziland: Central Bureau of Statistics and Marco International Inc., 2008.
5
The National Multi-sectorial Strategic Framework for HIV and AIDS, 2009-2014

11
Susceptibility Testing (DST) survey conducted in Swaziland from 2009 to 2010. It is
established that more than 7.7% of all new TB cases are multi-drug-resistant TB (MDR-TB)
cases and that 33.4% of retreated cases are also MDR-TB cases. This prevalence level puts
Swaziland in the league of most affected countries worldwide.6
The HIV/TB co-infection
rate among TB patients is 82%.7
By mid-2000, health services were overstretched and unable to cope with this
overwhelming situation without partner support. The increasing number of people in need
of HIV care and anti-retroviral treatment (ART) and the high number of undiagnosed and
untreated DR-TB cases required a radical scale-up of all HIV and TB services through fast
decentralisation to the level of the communities. Among other gaps and weaknesses in the
response to HIV and TB, lack of human resources was recognised as the main obstacle to
expand capacity of health services. In 2004, 44% of physician posts, 19% of nurse posts and
17% of nursing assistants were unfilled. The main reasons were ‘brain drain’ and attrition
by HIV related illness and death. In addition, public hiring was and still is restricted by the
IMF zero growth policy. The MOH tried to respond to the human resources crisis by
international recruitment and was ready to experiment task shifting as recommended by
the WHO.8
In 2007, following an invitation of the former prime minister, MSF-OCG9
carried out a
needs assessment in predominantly rural Shiselweni region in southern Swaziland, the
region being considered the most disadvantaged of the four regions at that moment. A
memorandum of understanding between MSF and MOH was signed and MSF started to set
up its support for the implementation of decentralisation of HIV/TB care by the end of
2007 with the following objectives:
• to establish community-based, decentralised, integrated ART and TB treatment
• to set up comprehensive care for TB and HIV including drug resistant TB
• to enhance TB and HIV prevention through large-scale community involvement
The major strategies to achieve these objectives were 1) decentralisation of services, 2)
task shifting, 3) patient-centred ‘holistic’ approach aiming at comprehensive one-stop
services covering medical care as well as patient support, education and counselling (PSEC),
and 4) involvement of the communities.
1.1.2 Overview of the implementation
Shiselweni region has a population of 208 45410
, among them 40 000 are estimated to be
living with HIV.
The region has 14 constituencies (‘Tinkundlas’) which function as administrative centres. It
is also divided into three health zones11
with a central health facility for each zone (either
hospital or health centres with in-patient capacity). These referral centres are called
6
MSF-OCG. Swaziland Mission Strategy Paper 2012. Mbabane, 2011.
7
WHO. Intensifying TB case detection. Update 2011. www.who.int/tb (accessed April 30 2013).
8
MSF-OCG. Swaziland Mission Strategy Paper 2012. Mbabane, 2011.
9
MSF will be used in the rest of the document as a synonym for MSF-OCG.
10
Central Statistical Office. 2007 Population and Housing Census. Mbabane: Central Statistical Office, 2010.
11
They are called Hlatikulu, Nhlangano and Matsanjeni.

12
mother facilities. Hlatikulu health zone has a government hospital, the Nhlangano and
Matsanjeni health zones have health centres. There are 22 primary health care clinics
(baby clinics) in Shiselweni region including four that are not operated by the
government.12
Clinics depend on/report to their respective zonal mother health facility and
their zonal MOH supervisors who are part of the regional health management team.
Over the past five years MSF supported the stepwise roll-out of the decentralisation of HIV
and TB care to all the 22 clinics. At the same time health promotion, defaulter tracing,
mobile HIV testing and counselling and TB screening as well as MDR-TB home care were
decentralised to community level. By the end of 2011 more than 6000 patients in
Shiselweni were on ART in clinics, more than 1785 patients enrolled in TB treatment and
more than 180 patients on DR-TB treatment with 2nd
line drugs. ART coverage in Shiselweni
increased from 33.4% (95% CI: 21.2 – 45.3) in 200713
up to 77% by end-201214
. The
regionwide roll-out of the programme for prevention of mother-to-child transmission
(PMTCT) was primarily supported by the Elisabeth Glaser Paediatric AIDS Foundation
(EGPAF), a implementing partner of MOH funded by the US President Emergency
Programme for AIDS Relief (PEPFAR). Paediatric HIV care has also been decentralised to
clinic level primarily by MSF but is also offered in a specialised clinic run by the Baylor
College in Hlatikulu hospital.
MSF decided to concentrate its efforts on clinics and did not support mother health
facilities, except for TB care, particularly MDR-TB, laboratory and some additional human
resources.
Task shifting was instrumental for decentralisation and for scaling up and of HIV and TB
services.
During the first phase clinics were regularly visited by a mobile MSF team for ARV refill. On
site ART initiation by an MSF doctor was later added while nurses were doing follow-up
and refill of stable patients. In order to enable clinics to offer daily ART initiation, MSF later
seconded one additional nurse per site to help them cope with the increasing workload.
Once Nurse-led ART Initiation (NARTIS) was green lighted by MOH. This task was also
officially shifted to nurses, while doctors kept visiting clinics weekly or every fortnight to
see patients with complications and continue mentoring nurses.
Meanwhile, many tasks were shifted from nurses to lay people. HIV testing and
counselling, pre-ART counselling and adherence counselling was shifted to expert clients,
drug dispensing to pharmacy assistants/dispensers and laboratory tests first to HIV
counsellors and testers (HTC), who were later upgraded to phlebotomists. While additional
doctors and nurses were recruited mainly from Zimbabwe, all the new categories of lay
health workers were hired by MSF from the surrounding communities.15
The task shifting
process was accompanied by initial on-the-job training, multiple formal training courses
12
According to the latest update from the field, there are at least 24 baby clinics that include 6 private clinics.
13
Swaziland Demographic and Health survey, 2007.
14
MSF-OCG. Annual programme report Swaziland, January-December 2012. Mababane: MSF-OCG, 2013.
15
Expert clients had to be disclosed, adherent to ART and from the surrounding community. No specific basic
training level was required. More specialised positions HTCs, phlebotomist, pharmacy assistants were
partially recruited among well performing expert clients partially from outside. Being HIV positive and
disclosed was not a prerequisite.

13
and mentoring and was followed by on-going supervision. Among the training courses for
nurses were Integrated Management of Adolescent and Adult Illnesses (IMAI) and NARTIS.
Once ART services were established at clinic level, many patients who had been followed
up at mother health facilities were transferred out to the nearest clinics.
In parallel to ART decentralisation, decentralisation of drug-sensitive DS-TB treatment took
place. MDR-TB treatment was decentralised from the specialised hospital in Manzini to
mother health facilities with daily observed treatment (DOT) at clinics or at home with
community treatment supporters and community TB nurses. A new MDR-TB ward for
initial hospitalisation and for admission of complicated cases was constructed by MSF in
Nhlangano health centre in 2011.
Community expert clients, who serve as link between health facilities and communities, are
involved in health promotion and defaulter tracing and recently also in mobile HIV testing
and TB screening.
The decentralisation process has been complemented by logistical support, strengthening
of infrastructure and infection control, upgrading of laboratory services including the
introduction of new technologies for TB diagnostic (GeneXpert), TB drug sensitivity testing
and viral load in mother health facilities, set-up of mini laboratories with point of care
machines for CD4, haematology and blood chemistry in clinics, sample transport system
and supply of drugs and other commodities that are not covered by MOH. Research has
been carried out to inform the development of new strategies and provide evidence about
effectiveness of others.
In parallel MSF has been active in advocating for and supporting the development of new
guidelines and policies, like the national task shifting framework16
, a key policy document
developed in 2011 for the formalisation of task shifting.
1.1.3 Rationale for the study
After five years of roll-out and achieving major mile stones in the decentralisation of HIV
and TB care in Shiselweni, it was considered important to carry out a comprehensive
evaluation of the effectiveness and efficiency of this decentralised model of care with the
purpose to
• capitalise the experience within MSF for similar projects elsewhere,
• share the experience with MSF partners in Swaziland and possibly promote its
replication in the entire country,
• share this decentralisation experience widely through publication and
• to specifically describe the experience on task shifting in order to support development
of internal MSF guidelines for replication.
As a component of the overall evaluation it was considered crucial to also include a
qualitative study to explore the different stakeholders’ perception of the process and the
achievements.
16
Ministry of Health. Swaziland Task Shifting Implementation Framework. Draft. Swaziland: Ministry of
Health, 2011.

14
1.1.4 Objectives of the perception study
The main objective of this qualitative study is to explore and understand the perception of
the decentralised model of care of HIV/AIDS and TB in the region of Shiselweni, Swaziland
by different groups of stakeholders: patients and the wider community, health workers
from the respective health facilities, MOH and MSF coordinators and other national and
international HIV/TB actors.
Specific objectives of the study are to analyse the perception in regards to the following
issues:
• role and objectives of decentralisation (including task shifting) of HIV/TB care in
Shiselweni,
• the implementation process to achieve decentralisation (including task shifting)
• the outcome and impact of decentralisation (including task shifting), namely access,
acceptability of services, quality of care, coverage and stigma
• the use of decentralisation (including task shifting) as strategy at national health policy
level
1.2 Methodology
1.2.1 Study setting and population
In order to cover a large geographical area and the different levels of health facilities it was
decided to include one central health facility and two clinics per health zone (one best
performing, one worst performing) as study sites.17
The selection of the two clinics per
health zone was done by the MSF coordination team based on the following performance
criteria: level of attendance, achievement of programme indicators, skills/performance of
staff and level of service organisation. The following sites were included in the study:
Name of facility Criteria
Mother health facility level
Hlatikulu regional hospital Central health facility
Clinic level
Hlatikulu health zone
Nkwene clinic best performing
Nhletsheni clinic worst performing
Nhlangano health zone
Mahdlandle clinic best performing
Mashobeni clinic worst performing
Matsanjeni health zone
Our Lady of Sorrows clinic, Olos best performing
Lamuvisa clinic worst performing
17
See map of Shiselweni region with health facilities in chapter 5.1.

15
In addition, health workers (nurses, expert clients, pharmacy assistants) from other clinics
were interviewed in focus groups outside of the facilities for triangulation reasons.
To cover the perspectives of all the different stakeholders the following groups of
informants were included in the study population:
• Health workers of MOH and MSF of different professional groups working at the
selected sites or in the surrounding communities: medical doctors, nurses,
phlebotomists working in mini laboratories, pharmacy assistants/dispensers, expert
clients/ counsellors. Expert clients being patients and from the community themselves
served as key informants for patients’ perspective at the same time.
• HIV and TB patients using services from or living in the surrounding area of the seven
selected study sites (health facilities)
• Community leaders (traditional leaders, traditional healers, religious leaders, rural
health motivators living in the surrounding areas of the six selected clinics
• Regional and national supervisors/coordinators of MOH
• Regional and national and head quarter supervisors/coordinators of MSF
• Other national and international HIV/TB actors 18
1.2.2 Study design and sampling
A study protocol developed by the team of investigators was approved by MSF Ethics
Review Board and Swaziland Ethics Review Board.19
Different qualitative research methods were used: Semi-structured individual interviews,
interviews with two participants and focus group discussions. Most interviews were face to
face. A few interviews with stakeholders of MOH, MSF and other actors were conducted by
phone. For this purpose interview guides20
had been developed prior to the field visit
covering topics related to the specific objectives. Purposive sampling was used for this
study.21
1.2.3 Data collection
Data were collected between 21 November 2012 and 10 February 2013 with a field
presence in Swaziland from 30 November to 22 December 2012.
A total of 118 sessions were conducted by the primary investigator and the two
international co-investigators: 105 individual interviews, five interviews with groups (of
two people) and eight focus group discussions. Informed consent was sought and
anonymity was ensured to interviewees. Where possible, interviews were conducted in
18
See list of interviewees in chapter 5.2.
19
MSF-OCG. Evaluation of the decentralisation strategy for HIV/TB care and task shifting in Shiselweni,
Swaziland – Perception and acceptability. Study protocol. Geneva: MSF-OCG, 2012. (available on request)
20
See interview guides chapter 5.3.
21
For detailed information about selection of study participants please see chapter 5.2.

16
English. Where needed, interpreters, hired for this purpose, translated during interviews.
In addition to note taking, the interviews were audio recorded apart from a few
exceptional cases of refusal from respondents’ side. Twenty six interviews were
transcribed by a separate team. For the remaining interviews extended field notes were
written in electronic format by the interviewers.
At the end of the data collection the research team concluded that saturation had been
achieved.
1.2.4 Data analysis
The study employed a framework analysis22
approach. Nvivo 10 software, a specialised
programme for qualitative data analysis was used to assist in data management and
coding. Interviews were primarily coded by the first international co-investigator. Some
interviews were double coded to increase validity. While analysing content and emerging
themes, similarities and possible contradictions of the perception of certain issues by
different stakeholder groups were searched. Triangulation of findings from different
sources of information was used for validation.
Throughout all stages of the analysis findings and final conclusions were discussed in an
iterative process among the three international field research team members. Preliminary
findings were also discussed with the national co-investigators. This further increased the
validity of the findings. Early feedback from MSF was sought during the presentations of
the first findings to the field coordination and headquarters’ operational team.
1.3 Limitations
Although the field researchers were external to MSF in Swaziland, it is likely that they have
been perceived as being associated with MSF. This might have caused some response bias,
even though the independent nature of the investigators has been explained to the
informants and they have been encouraged to be as open as possible with their feedback.
The selection of informants among HIV/TB patients at health facilities and from existing
support groups may have biased the findings about patients’ perception towards those
who are more satisfied with the services. Information about reasons not to use the existing
services was only obtained indirectly through health workers, patients and key informants
from the community.
Patient informants from existing support groups showed a relatively high level of
empowerment and readiness to disclose. This is not necessarily typical for the general
patient population but could already be a positive result of mutual peer support in the
support group itself. Keeping an exact gender balance proofed not to be feasible; like in the
health programme, women were overrepresented.
22
Ritchie, J., and L. Spencer. Qualitative data analysis for applied policy research. Analyzing Qualitative Data.
Edited by Bryman A, Burgess RG. London: Routledge, 1994. Srivastava, A., and S. B. Thomson. “Framework
analysis. A qualitative methodology for applied policy research”. Research Note JOAAG, Vol. 4. No. 2, 2009.

17
The ART programmes of mother health facilities have only received a limited support from
MSF compared to the primary health care clinics. This must be taken into consideration for
the interpretation of findings about Hlatikulu hospital. A good number of interviews with
patients and community leaders had to be translated. It is possible that the translation did
not always capture the exact meaning of questions and answers. This has also limited the
depth of the translated interviews.
Available time and budget limited the number of verbatim transcriptions. For the same
reason, no back translation was possible for the translated and transcribed interviews.
Due to the big sample size the number of double coded interviews had to be limited.

18
2 Findings
2.1 Perception of objectives and role of task shifting
The objectives of decentralisation were well understood by all interviewees as bringing
HIV/TB services closer to people, thereby improving access and ultimately reducing related
morbidity and mortality.
All respondents agreed on the high relevance of decentralisation of HIV and TB care in the
context of Swaziland in general and Shiselweni region in particular. In this region HIV and
TB prevalence are very high, the majority of the rural population is poor and cannot afford
the transport cost and mountainous landscape makes remote places inaccessible to
vehicles. All these factors resulted in high defaulter rates and low coverage in the past.
Decentralisation was also perceived as relevant to decongest overcrowded mother health
facilities.
Task shifting is understood by MSF as well as by MOH coordinators as a very relevant
means to achieve decentralisation given the limited number of qualified human resources
available for health in Swaziland. This matches with the experience of other similar
contexts23
:
“The objective of the decentralization was to decongest the facilities and taking the services to the
communities, and on another note it was a way of helping the clients because moving from the
communities to the central facilities was costly and we were seeing a lot of defaulters.” (MOH)
24
2.2 Implementation process
Adequate staffing with sufficiently qualified human resources is essential to ensure
decentralised HIV/TB care at primary health care level. In Shiselweni region this was
achieved through recruitment of additional staff, involvement of lay cadres, capacity
building, on-going supportive supervision and task shifting. This process entailed many
changes for individual health workers and clinic teams. It also increased the health services
management and supervision needs at regional level and required changes in national
policies. Infrastructure, laboratory support, drugs and commodity supply needed to be
strengthened and complementary community-based activities developed. The perception
of this process and the changes it provoked are laid out below.
23
Kurniasari, Miladi. HIV/TB decentralisation in Africa: a literature review. Vienna: MSF Vienna Evaluation
Unit, 2012.
24
See chapter Glossary of quotes5.5 for glossary of quotes

19
2.2.1 Human resources and task shifting
Recruitment
In general, the process of recruitment of new staff was not a subject of great discussion
among informants.
However, regarding the recruitment of new lay health workers some questions in terms of
the need for a minimum level of education were raised by MSF and MOH nurses and
supervisors as well as by lay cadres themselves..
Some nurses expressed that having a higher level of education would have eased expert
clients’ capacity to follow training courses and some of the more complex tasks. Other
nurses had not perceived this as an obstacle.
In addition, having completed form five of secondary education (O-level) has been
reported to be a prerequisite for future absorption by MOH as well as for admission to
certified training courses like HTC, phlebotomist or pharmacy assistants. Therefore, the
expert clients who were hired without this minimum level of education have now no
option for career development. Supervisors therefore suggest to make O-level a
recruitment criteria for lay people or alternatively sponsor further education for well
performing expert clients, as MSF has done for phlebotomists. This is also a request from
expert clients themselves:
“We should also take more care of the level of education from the beginning because later on it
prevents us to upgrade them, […] when they get more and more competent.” (MSF supervisor)
Being from the nearby community and accepted by the community25
as part of MSF’s
selection criteria was positively highlighted by MSF, by some nurses and by a coordinator
from MOH because it increases the acceptability of services. At the same time the
pertinence of this criterion was questioned both by some health staff and patients because
of issues of confidentiality.26
Some people might fear that confidentiality wouldn’t be kept
by their family or community members who work in the clinics.
A new practice of involving MOH senior nurses of the clinics along with community health
committees in the selection of new lay staff was perceived as a good strategy facilitating
their acceptance in the clinic team.
Training and mentoring
All clinic staff, medical and lay, as well as MOH coordinators and partners praise MSF’s
effort invested in staff training and the high standard of training.
All the different cadres of health staff, nurses as well as the new (lay) cadres are greatly
satisfied with the on-the-job training, the formal training courses, continuous education
and refresher courses.
25
MSF partially involved community health committees in the selection procedure as a means to assure
acceptability.
26
See also ‘Acceptability of task shifting‘ on page 27.

20
“MSF came and trained us. With its help, we became more knowledgeable: we can initiate ART and
TB treatment. We attend workshops every now and then, so we feel more confident now in
managing clients.” (Nurse MOH)
They particularly value the mentoring aspect which helped them to further develop their
skills and their self-confidence:
“When I first started here there was the MSF nurse, he would just […] listen to my health education
session and after that he will tell me that it was good but I have to improve there and there. […] And I
think that made me to become more effective and more confident.” (Expert client)
Similarly to what is described in the literature on task shifting27
in other countries the
importance of mentoring after formal training courses was also highlighted by coordinators
and supervisors from MSF, MOH and other actors as well as by health workers themselves:
“Chronic disease management is more complex and more difficult to teach, requires a lot of
monitoring. […]Trainings are good if they are accurate, task by task, if they are frequent, with
refreshers, also a lot of supervision.” (MSF coordinator)
Expert clients particularly highlight the importance of continuous education to update their
knowledge because they are the ‘entry point of care’ and need to be able to provide
accurate information.
Prioritisation of MSF staff over MoH staff as well as clinic staff over mother health facility
staff was an issue for some respondents. Some critical remarks were made by a MOH nurse
and some MOH coordinators that MSF initially focused on training their own staff and
prioritising lay staff. A staff member of the Hlatikulu hospital perceives clinic nurses being
prioritised for training over hospital nurses of the ART department.
MSF coordinators highlight the benefit of using government curricula and certified courses
whenever available to enable future staff absorption. An attempt to provide a professional
training course for pharmacy assistants based on a curriculum of a South African University
had failed for two reasons: 1) due to insufficient commitment of the trainer and 2) due to
lack of recognition of the training course by MOH.
Supervision and support
In conformity with what is said in the literature28
, continuous supportive supervision is
perceived by all parties as a critical condition to ensure the quality of services provided.
This key factor is acknowledged and seems to have been taken very well into consideration
through regular supervision by MSF that includes clinic visits, phone support, feedback, etc.
Monthly multidisciplinary team meetings with zone clinic supervisors present are perceived
as good additional forum for clarification of questions. The staff also appreciate the
possibility to request ad hoc support for complicated cases by phone. Overall the system
seems to work well and staff unanimously confirm that they feel very well supported in
their jobs:
“Our supervisors are always there for us: whenever I have a question or a problem, I would contact
my supervisor.” (Expert client)
27
Unit, 2012.
28
Unit, 2012.

21
Counsellors are happy about the possibility to request specific emotional debriefing from
their technical supervisors but also seek peer support from colleagues at the clinic.
Some negative remarks were made by staff about the multi-layered supervision system
that sometimes causes confusion to identify the right reference person: the senior nurse of
the clinic, the technical referent/doctor, the zone supervisor of MSF or MOH:
“I have three supervisors: one is in Nhlangano, one in Hlatikhulu, then the one in the clinic. You find
that there is confusion on what is expected of me.” (Phlebotomist)
Despite some collaborative supervision of MSF and MOH, the supervision activities from
the latter seem inadequate to respondents. A matter of strong concern for many
coordinators from MSF, MOH, other HIV/TB actors and for clinic nurses is the fact that the
MOH still relies a lot on MSF’s supervisory system in the region. MOH ART doctors from
Hlatikulu hospital often don’t have enough time to visit the two clinics they are supposed
to supervise. Time and transport constraints also hinder MOH primary health care zone
supervisors to jointly visit the clinics with MSF.
“Usually it is up to the MOH to […] pass by but it is MSF who comes, does a thorough check-up and
see if there are problems. But the ministry, they do not have time.” (Nurse MOH)
Staff skills and competences
Respondents from the health sector feel that decentralisation and capacity building that
came with it have strongly increased skills and competences of professional nurses and all
the different categories of lay staff in the clinics. Task shifting as a strategy of
decentralisation is perceived to have empowered staff.
Clinic nurses’ as well as lay staff’s self-perception showed that they feel confident to carry
out the new tasks, that they developed a lot of skills and are constantly gaining new
knowledge. Some statements reveal how proud they are about their new competences.
However, clinical management of paediatric HIV patients is an area where nurses still feel
more insecure and continue to be mentored by medical doctors.
“I am happy to do ART initiation. I feel empowered, excited, I know a lot of things I did not know
before.” (Nurse MOH)
Supervisors from MSF and MOH gave a very good feedback on clinic nurses’ competences,
though the level of MOH nurses was still felt to be a bit lower than the one of MSF nurses.
Nurses in clinics are now able to initiate ART and DS-TB treatment without the support of
doctors:
“Another success […] is staff development. MSF has supported MOH activities. […]. Our nurses are
able to manage clients on ART, now I can say they are small doctors. […] Now the TB people they can
manage […] the client in the clinics.” (MOH)
The nurses in Hlatikulu hospital seem to have profited less from the efforts of staff
development. This was explained by higher rotation of nurses in the ART clinic (new nurses
are not always immediately trained on ART), permanent presence of doctors in the ART
clinic and consequently less task shifting to nurses. Up to now only doctors initiate ART
there.
Staff members with lay background (expert clients, HTCs, phlebotomists and pharmacy
assistants) all feel confident in their jobs too. However, state recognition and official
certificates are still very important to them. The pharmacy assistant trainees urged that

22
they want to get official certificates and sincerely hope that they will be admitted to the
recognised training course in 2013. Phlebotomists hope that with their MSF training they
will soon be officially recognised as laboratory assistants.
In addition, expert clients enthusiastically stressed how much they personally have grown
through their new job:
“Today we are no longer the same as we were before. We are proud of being expert clients and we
are proud of our work […]. We love our job.” (FG expert clients)
All these new categories of health workers overall received a very good feedback from
nurses and from MOH and MSF supervisors / coordinators. Phlebotomists are respected by
nurses as professionals with a technical expertise they do not have themselves. They are
also perceived as having more competences than their colleagues from other regions.
Pharmacy assistants are seen as qualified for the job they are doing, even asking critical
questions about nurses’ prescriptions.
"Really their (lay staff’s) level of understanding and handling of the patients is good.” (Nurse MOH)
With few exceptions, where nurses had some doubts about the competence of expert
clients related to their basic education, expert clients were well trusted and perceived by
some as “experts” in counselling and as critical thinkers.
“They called them for a stepped-up adherence workshop, which actually as a nurse myself, if I were
to deliver that, I’m sure I would have a problem, but expert clients are experts in doing that because
they have been trained.” (Nurse MSF)
Hlatikulu hospital seems to face more problems with expert clients’ competences than
clinics. There, however, expert clients were not hired by MSF, did not receive training by
MSF and do not benefit from the on-going MSF support and supervision.
Employment conditions
Different comments were made about the employment conditions of various cadres of
staff either hired by MOH or MSF. Most of the additional staffs hired for the
decentralisation of HIV/TB care in Shiselweni region are under MSF contracts.29
Salaries of
MSF staff are similar to MOH scales to ease future absorption.
Most comments were made about the expert clients’ salary. All groups of interviewees
consider their salary as far too low given the importance and the number of tasks they are
in charge of.30
Increasing their stipend was highlighted as a priority by many in order to keep them
motivated and to ensure that the quality of their work does not suffer.
“Even the nurses recognise that they do a lot of work and they ask us, please revise their stipend so
that they stay motivated.” (MOH)
The national task shifting framework31
foresees better salary conditions for their category
in the future. However, the prospects of being absorbed by MOH under better conditions
29
This differs from other regions where most of the new additional staff has MOH contracts that are financed
by implementing partners.
30
1100 Swaziland Lilageni/month = 118 USD
31
The national task shifting framework foresees absorption of expert clients as “Health Motivators 1”, paid 3
times more than what they are currently earning. O-level certificate is required.

23
only apply to those with completed secondary level education. It is, therefore, not a
realistic option for all of them.
Compared to expert clients the salary situation for phlebotomists and pharmacy assistants
in training is considered to be better. Phlebotomists however are perceived as underpaid
given their tasks and the training they received. MSF coordinators think that they deserve
to be recognised as laboratory assistants.
Due to the scarce availability of qualified human resources for health in Swaziland, salaries
of nurses in the country are quite high. No complaints were voiced by this group, despite
the fact that ART initiation has been added to nurses’ job description.
Contrary to permanently employed MOH staff MSF contracts are renewed every year
which is leading to some complaints especially among expert clients due to the insecurity.
Despite some frustrations expressed regarding employment conditions, it is impressing to
see how many health workers from all categories feel compensated just by the fact that
they are able to help patients32
:
“For me, as long as I save lives I don´t care about money. Sooner or later I will get the benefits of it. I
am a life saviour.” (Expert client)
Staff health
Staff health is recognised as a major concern for MSF due to the high HIV prevalence
among health workers. Interviewees appreciate that MSF guarantees a health care package
to all staff and their families under MSF contract including expert clients, which is not the
case in other regions.
“With MSF in Shiselweni it is a unique region… Expert clients have access to medical aid and in the
other regions they don’t have that. I am really grateful for that.” (MOH coordinator)
Expert clients are particularly grateful that MSF as their employer is not only concerned
about patients’ health but also about staff health.
“You can see that MSF really cares for us as well as for the people out there.” (FG expert clients)
Informants also mentioned MSF’s specific TB prevention efforts as having a positive impact
on the reduction of staff’s health risk. Employees seem well acquainted with the TB
infection control and reported to implement the recommended measures. However,
health workers also complain that some clinic premises, e.g. counselling rooms, are still not
ventilated well enough. Safety during sputum collection is a particular concern. Therefore,
this task has been recently shifted from expert clients to phlebotomists to reduce exposure
of HIV positive staff to TB. However, some phlebotomists express that this is not a
satisfactory solution since some of them are also HIV positive. Wearing a mask
systematically is considered uncomfortable and not well accepted by patients and masks
don’t seem to be readily available all the time, especially for those working in the
community.
Another concern expressed by expert clients’ supervisors is their exposure to stress due to
challenging counselling sessions but also due to overload with tasks. They caution that they
generally don’t dare to complain much because they fear to lose their jobs.
32
See ‘Motivation and work satisfaction’ on page 26.

24
Expert clients themselves describe their counselling work as very psychologically
demanding. MSF as well as the MOH’s national programme try to prevent counsellors’
burnout by offering debriefings with supervisors, educating expert clients about self-
protection and peer support and organising workshops with a focus on care for carers.
Expert clients report making use of the different self-protection strategies but regret that
regular counsellor meetings at zone level are not held anymore:
“When I counsel a patient and his CD4 is low he should start ART. […] When he refuses we end up
feeling stressed and overloaded. […]. Sometimes it gets to a time where I need to debrief myself to
my supervisor or any other staff inside the clinic. I usually share.” (Expert client)
Distribution of tasks
Today, the overall task distribution among the different cadres in the clinic seems to be
perceived as effective by all cadres, medical and lay.33
Only in Hlatikulu hospital counselling
of new HIV positive patients by expert clients is a concern for nurses. In their sight it
reduces patient flow and enhances the risk of loss of follow-up. Therefore, they would
prefer it to be done by nurses.
Clear job descriptions for the new cadres are perceived as very important and helpful to
organise a clear distribution of tasks in the clinic.
TB injections shifted from nurses to lay community treatment supporters. This is very
controversial because it is considered as a medical responsibility and requires specific
qualifications as well as legal protection in case of incidents.34
Changes in workload – adequate staffing
The distribution of workload has changed with the decentralisation of HIV and TB care and
task shifting. While nurses and doctors of Hlatikulu hospital and Baylor clinic reported that
work load has reduced in mother facilities, decentralisation has increased the workload in
the clinics.
More specifically, clinic nurses and their supervisors/coordinators recall how task shifting
from doctors to nurses has initially increased their workload, which caused resistance
among some of them to take on more duties, despite the fact that they saw the benefits
for the patients:
“Nurses had mixed feelings in the beginning. They knew that the patients defaulted because the
doctor was not always there. But on the other hand it meant more work for the nurses.” (MOH
coordinator)
However, task shifting of some of their duties to lay people and hiring of additional nurses
by MSF brought relief:
“The expert clients help us a lot. […] the workload for the nurses has changed really drastically. It
brought down the burden of talking most of your time to the patients. It was really a relief for the
nurses and for the patients too.” (Nurse MOH)
33
Nurses take on clinical consultations, doctors take on clinical consultations of complicated patients during
periodic visits in clinics, ART initiations in Hlatikulu hospital, expert clients take on counselling and some other
support tasks, HTC/phlebotomists take on rapid tests/mini laboratories and pharmacy assistants take on drug
dispensing.
34
See ‘Acceptability of task shifting’ on page 27.

25
Doctors are also happy with the task shifting of ART management to nurses because they
can concentrate on more complicated cases while being confident about the quality of care
provided by nurses. Reduced workload of nurses has also improved their attitude
according to observations of an MOH coordinator.
Another important observation of clinic nurses is that with the increasing number of ART
initiations at clinics the number of consultations of patients with recurrent opportunistic
infections has reduced. This had a positive effect on the workload:
“Things have improved a lot. In previous times we saw about 100 patients/week who came for OI
treatment and who they referred. […] The rate of acute curative consultations has reduced a lot.”
(Nurse MOH)
While most clinic staff and community expert clients feel that with the present numbers of
staff35
the current workload in clinics is manageable, others feel that sometimes they are
still overloaded. When asked to specify, it appeared that partially some organisational
reasons are underlying. Workload is not equally distributed over the day and during the
week. In other words, morning hours and some days of the weeks are busier than others,
data collection and reporting is perceived time-consuming. Staff absences negatively affect
work organisation. This is especially the case, when the phlebotomists are absent since
they are the only cadres trained and authorised to manage the point-of-care machines. In
their absence, samples have to be sent to the mother health facility, which generates
delays and risks of defaulting/loss of follow-up. Pharmacy assistants complained more
about the work being too much than other health providers:
“Truly speaking, our workload is too much. In terms of packing the tablets while there are patients
queuing, had we not the extra support which is the expert clients.” (FG pharmacy assistants)
MOH highlighted that some clinics are overstaffed while others are understaffed and that
staffing norms need to be developed to be able to measure more objectively. The Clinton
Health Access Initiative with Human Resources Alliance for Africa is supporting the
development of the tool.
Motivation and work satisfaction
All health workers interviewed show a high level of motivation and work satisfaction.
Expert clients are especially passionate. They find it very rewarding to see the effects of
being role models, i.e. convincing clients to test, accept their HIV status, live positively,
adhere to ART, cope with side effects and finally recover. Their satisfaction seems to be
further enhanced by the recognition and trust they receive from their clients and the
community:
“I love my job as an EC, […] because I am motivating people every time. I always tell them to look at
me; I am fresh and I’m beautiful but I am taking my ARVs. […]I just like the fact that I am a role model
to them and they always come to me.” (FG expert clients)
Some potentially demotivating factors for expert clients were named by MSF, MOH and
expert clients: the fact that expert clients are being partially abused by nurses to “do all the
35
2-3 nurses, 2 clinic expert clients, 1 phlebotomist, 1 pharmacy assistant, about 2 community expert clients
per clinic.

26
donkey work”, the fact that they only receive a small stipend and that only those with O-
level have a chance for career development despite good job performance. 36
Some nurses were equally passionate in describing their motivation and work satisfaction.
They feel empowered by the new skills and are eager to learn more and take over new
tasks. Also, they feel excited about being able to initiate ART and are very happy to be able
to improve their patients’ health:
“When you’ve seen someone critically ill and then later you see him healthy and running around, you
feel satisfied that at least we are able to serve the people.” (FG nurses)
While the demotivating factor of the initial increase of workload for MOH nurses has been
mostly overcome, some MSF staff observed that the level of motivation among them still
varied.
Pharmacy assistants and phlebotomists also expressed a high level of motivation. Some of
them had worked as expert clients before and had been upgraded to the current positions.
Their underlying motivation was the same as the one of expert clients. Others, like many of
the pharmacy assistants, applied directly but with a equally high motivation.37
Interdisciplinary team relationship after integration of services
Decentralisation and integration of HIV/TB care meant a lot of changes for the clinics: 1)
the full integration of HIV and TB care and treatment into the clinic services, 2) the
integration of the MSF staff into the MOH or private/mission clinic team and 3) the
integration of the new lay cadres into the new interdisciplinary clinic team.
After several years of this sometimes challenging process, most MOH/mission and MSF
staff perceive the interdisciplinary teams now working hand in hand as “one family”:
“I think we are one happy family; one big happy family. We are learning from each other, when there
are mistakes or […] gaps, we sit down and talk about them together and then we find a way forward
as a team. There is no one who is side lined, there is no one who is either a MOH nurse or an MSF
nurse; we are just one.” (MSF nurse)
This was, however, not always the case. Both MOH and MSF supervisors, coordinators,
international HIV/TB actors and MSF nurses recall that MOH nurses initially had the
tendency to see HIV patients as ‘MSF patients’ and to leave them aside to be seen only by
MSF staff. This challenge was apparently overcome by training more nurses in IMAI and
NARTIS and by intensified mentoring with the effect of MOH/mission nurses now being
fully involved in HIV/TB care:
“Shiselweni region has done very well very quickly but there was a problem: the nurses seconded by
MSF did more on HIV services, and the other (MOH) nurses did not get involved. Then we did training
for the other nurses and asked them to take on the tasks of HIV care and now we see the difference,
improvement in terms of MOH nurses involvement.” (MOH)
MOH coordinators underlined the importance of pushing supervisors and managers for
integration of TB and ART care while decentralising services.
36
See ’Employment conditions‘ on page 22.
37
In 2012, MSF hired pharmacy assistant trainees with O-level qualification with the aim to sponsor the new
officially recognised pharmacy assistant training. They are working as trainees under MSF supervision
intending to start their official training in 2013.

27
Interviewees also described that in the past there had been a certain tension between
MOH and MSF staff in some clinics because of unclear staff management lines for MSF
employees that were seconded to the clinics. Senior MOH nurses as well as MOH and MSF
clinic supervisors and coordinators report, however, that this problem has been
successfully solved and that all MSF seconded staff are now managed by the senior MOH
clinic nurse in terms of day to day issues.
While some nurses recall that they were initially sceptical towards lay staff and other
informants of MOH said that discrimination towards HIV people used to be a barrier for the
integration of expert clients into the teams38
, these problems seem to be over now, as
most interviewees from all the different lay cadres as well as their supervisors confirmed:
“Cooperation with nurses in the clinics is now good. They are collaborating with ECs, supervising
them. There are just some minor internal problems but not big ones.” (MSF supervisor)
Among minor problems nurses mentioned issues like lay staff taking too much initiative
and making decisions that were out of their scope. In Hlatikulu hospital there was not
enough trust in ART counselling done by expert clients.
While most interviewees among the different lay cadres expressed that they feel well
respected by nurses and their other colleagues in the team, some complaints were voiced
by them that in some clinics nurses showed an attitude of being superior and not
respecting their critical remark, e.g. a pharmacy assistant correcting a nurse prescription.
Pharmacy assistants were, therefore, looking very much forward to getting their official
certified training:
“Sometimes a person may not have a confidence in what we are saying due to our lack of formal
education, e.g. patients from community. This is the passport of gaining a little bit of respect […].”
(Pharmacy assistant)
Acceptability of task shifting
Nowadays, all categories of informants perceive task shifting as pertinent, effective and
necessary for providing good quality HIV/TB decentralised care at clinic level in Swaziland:
“People are happy with this arrangement and better qualities of care despite lower cadres deliver
care. I have seen success stories in clinics. Now patients do not even think of going to the health
centres.” (MSF supervisor)
Initially reluctant, MOH today largely recognises the benefit of MSF’s task shifting strategy,
including to new lay cadres, and is very grateful about the huge support MSF has invested
to make it happen. Although opposed at the beginning, today all nurses have accepted the
new clinical tasks shifted to them, some are even very proud of it. At the same time they
agree that the clinics would not have been able to cope with the current workload without
the support of lay staff. Other HIV/TB actors acknowledge MSF’s immense investment in
terms of human and financial resources and praise the quality of the task shifting
implementation. Patients and community leaders did not specifically comment on task
shifting as such but considered the services provided at the clinics as of high quality, if not
even higher than at the hospitals, and reported to feel effectively cared for by all staff at
the clinics, without distinction. MSF coordinators all confirm that task shifting was a
necessary strategy to ensure decentralisation of qualitative HIV/TB care in Shiselweni.
38
Interview with an MOH coordinator

28
“We used to rely on doctors by referring the clients to them but now we are more confident to
manage them. […] For me as a nurse, I think I love task shifting.” (Nurse MSF)
“Before, in the clinics, we had only one nurse. Now we have two nurses and also a pharmacist and
some counsellors. This is better.” (Patient)
Informants of MOH and MSF coordination as well as partners explain that MOH had
already foreseen task shifting as a means to improve provision of HIV care in Swaziland
before MSF’s support started. However, they had only intended to shift ART refill from
doctors to nurses and to add a few expert clients to help with counselling. MSF’s more
radical approach, including NARTIS and involvement of numerous non-medical staff, was
initially not welcomed at all by MOH. Resistance was especially felt at regional and clinic
level. Underlying fears were substandard quality of care, nurses’ fear of too much workload
due to clinical HIV/TB management and nurses’ fear to lose their jobs due to the delegation
of some of their tasks to lay cadres. The central level of MOH was said to have accepted
expert clients without problems and to have partially tolerated some unofficial ‘piloting’ of
further task shifting of MSF using their own staff. MSF was, however, confronted with a
particular resistance against task shifting to dispensers/pharmacy assistants. This was
apparently overcome when the NGO Management Sciences for Health underlined the need
in a report. MSF and MOH interviewees attributed part of the resistance against task
shifting firstly to the fact that MSF’s implementation approach in the early stage of the
project was perceived as too fast and aggressive and secondly to the fact that the idea of
task shifting was not properly introduced to MOH, in particular at regional and clinic level:
“What happened here was (that) MSF started the programme without involving the people who were
on board. There is a natural resistance to task shifting. I will urge that whatever change that is there,
let it start from a dialogue between the stakeholders on board.” (MOH)
From MSF side interviewees reported that many efforts were needed to first trigger a shift
at the central level of MOH and afterwards in the field. Two key elements are said to have
reversed the situation: 1) the success in terms of health outcomes and 2) the 2010
appointment of a task shifting coordinator working specifically on this issue, explaining the
concept to MOH counterparts and advocating for it together with other HIV/TB actors.
Step by step, MOH accepted the strategy and developed the national task shifting
framework (2011) that is largely inspired from the Shiselweni model. Nurses were then
officially trained in ART provision and NARTIS is now also a part of the basic nursing
training curriculum in Swaziland.
Even if task shifting is now globally approved, delegation of TB injections from nurses to
community treatment supporters is not. MSF implemented this on a case-by-case basis for
patients living in remote areas, in the absence of cost-effective alternatives. Patients and
community leaders who are experienced in it state no complaints.39
Nurses express
scepticism about lay people giving injections. Most MOH representatives are either
hesitant or in clear opposition to it. The main underlying reasons are fear of legal
consequences in case of an injection incident and opposition of the national nursing
council. In the sight of some regional MOH representatives and MSF coordinators
injections by lay community treatment supporters are currently the only feasible way to
39
However, the number of patients interviewed with such an experience was limited.

29
ensure MDR-TB treatment for few patients who live far away from their nearest health
facility. An international actor felt it would be acceptable if no other option was available:
“It has been a struggle for us to adapt to that, because we thought that these people are not
educated how to give injections, the right dose, etc. But it has helped the patients. We have seen
patients recovering.” (Nurse MOH)
Legal framework for task shifting
According to informants among MSF and MOH the first important legal base for nurse-led
ART management was the 2010 revision “Swaziland nursing scope of practice”. 40
In 2011, MOH developed a legal framework for task shifting. This document is based on the
WHO task shifting recommendations for HIV/TB care41
but also on the specific Swazi
experience and has been developed in collaboration with all relevant partners (WHO,
PEPFAR, ICAP, MSF, Swaziland Nursing Council, etc.). It precisely describes which tasks are
assigned to which cadres in the context of decentralised HIV/TB care.
Informants are not clear about the current official validity of the national task shifting
framework. It has been circulated as a draft but so far it has not been officially endorsed by
MOH. Apparently, as per some informants, there is fear that the National Nurses
Association will use it to request higher salaries because of NARTIS and TB treatment. An
MOH informant also mentioned that some difficulties might still be expected by the
Ministry of Public Service42
to approve new lay worker positions called Health Motivator 1,
who would correspond to expert clients. Last but not least, major budget issues are said to
be preventing MOH to move forward in terms of the implementation of the framework.
Once the positions will be opened and reflected in the national budget, as per MOH, the
framework can be considered as fully implemented.
Recognition of new cadres
MOH informants expressed their political will and the need to absorb expert clients as
official health cadres. However, they acknowledged that the pending implementation of
the task shifting framework and the basic education requirements are still posing some
challenges. MSF representatives view this as one of their advocacy priorities.
Phlebotomists are officially recognised since they all have gone through the MOH standard
training. However, MSF phlebotomists are far more qualified and carry a lot more tasks
than phlebotomists working in other regions. MSF is aiming at having them officially
recognised as laboratory assistants.
Pharmacy assistants working in Shiselweni currently have no official recognition, since they
did not go through the two-year formal training. However, they are effectively trained by
MSF, considered as extremely helpful by regional MOH and nurses in the clinics. Today,
MSF’s plan is to try to make them admitted part-time in the newly MOH standard training
in 2013.
40
Ministry of Health Swaziland. Nursing scope of Practice, 2010.
41
WHO. Task Shifting, Global Recommendations and Guidelines. Geneva: WHO, 2008.
42
The Ministry of Public Service is in charge of opening new public service positions.

30
TB injections by community treatment supporters are currently officially forbidden by MOH
at national level.43
2.2.2 Infrastructure strengthening
Health staff and regional and national coordinators appreciated the infrastructure
improvements carried out at clinic and mother health facility level by MSF. In their sight
these were essential for the absorption of HIV and TB services by clinics in terms of
providing necessary space for additional activities. Also, the improvements led to a better
environment to serve patients and to better hygiene and infection control for patients,
their families and staff. The following infrastructural improvements were mentioned at
clinic level: additional rooms for consultation, counselling room, mini laboratories,
ventilated waiting areas, sputum collection huts for improved infection control, boreholes
for water supply, waste areas, basic equipment and furniture. At mother health facility
level MSF infrastructural support was appreciated for the enlargement of the laboratories
and the construction of the TB ward in Nhlangano Health Centre that fully relies on natural
ventilation for TB infection control. MSF’s support to complete or renovate staff houses
was also positively mentioned. The effort to ensure TB infection control at the patients’
homestead level by improving ventilation or constructing separate rooms was highlighted
by respondents from all groups:
“There were rehabilitation needs in Shiselweni region and MSF helped us to improve the space and
infection control, install incinerators.” (MOH coordinator)
2.2.3 Laboratory support
There was a unanimous positive perception of the benefits of the decentralised laboratory
capacity in Shiselweni among all groups of interviewees.
Interviewees agreed that the mini laboratories with point-of-care machines, which have
been established at all clinics, have dramatically reduced the waiting time for laboratory
results of CD4, blood chemistry and haemoglobin. Therefore, as per interviewees, they
contributed to the reduction of defaulters and allowed earlier ART initiation:
“But the good thing about the laboratory decentralisation is that you can do more things in the lab
now. You can do CD4, which was initially done at health centres and it would take a week or a month
for the results to come back. […] It made it easier for us to manage the patients and we were no
longer losing our patients like we were a while back.” (Nurse MSF)
However, a challenge identified by clinic staff is the fact that only one person per site is
trained in using the point-of-care machines.
The sample transport system established by MSF for tests that need to be done at
reference laboratories was described as very reliable and as a relief for patients who had to
travel to mother health facilities before. However, unlike in other regions the sample
transport at regional level has not yet been taken over by MOH:
43
See ‘Acceptability of task shifting‘ on page 28.

31
“Even the transportation of samples from clinics to hospitals it was really a problem because no one
was coming up with a solution until MSF came to our region taking samples from clinics to health
centres. So now it is just smooth.” (MOH)
Interviewees added that the advances in TB drugs sensitivity testing introduced by MSF
with GeneXpert at mother health facility level and thin layer agar culture technique in
Nhlangano health centre have made diagnosis of drug resistant TB more efficient. The
introduction of viral load (available at Nhlangano health centre) is seen as a big positive
step improving the monitoring of ART adherence and treatment failure. From the MSF and
MOH coordinators’ perspective, paediatric TB diagnostic still remains a challenge at
national level.
“GeneXpert technique allows fast results. Before it took eight weeks of sputum culture to get results
on drug resistance. […] People were dying before they got the results.” (MSF coordinator)
MSF was praised by MOH and other international actors for its leadership in laboratory
technology in Swaziland, for having driven the laboratory decentralisation in the country
forward and for having changed the national discussion, e.g. around routine viral load
testing.
Upgrading a regional reference laboratory to a centre of excellence for HIV and TB over
(exclusively) strengthening the national reference laboratory was found pertinent by most
respondents from MOH and their implementing partners. A replication for the other
regions was suggested. Only one other international actor questioned whether it would
have been better to invest more in the national reference laboratory.
2.2.4 Drugs and other commodities supply
It was positively remarked that the government ARV supply is reliable. However, clinic staff
appreciated MSF’s ability to cover for weaknesses of the national supply system in terms of
other commodities. While some items are exclusively supplied by MSF (e.g. reagents for
point-of-care CD4 machine, second line TB drugs), MSF also frequently covers when drugs
for opportunistic infections and HIV and other rapid tests are out of stock::
“I order (HIV tests) from the national lab (MOH laboratory). So sometimes the government runs out
of stock and […] I don’t have a reliable supply of test kits. (Expert client)
Both MOH and MSF coordinators mentioned that the parallel buffer stock supply by MSF
was helping short-term but was somehow problematic, since clinics assumed the habit to
order straight from MSF instead of ordering from MOH, and MOH does not always know
what MSF supplies.
However, the advantage of being able to jump in with a buffer stock was highlighted by
many respondents. One international HIV/TB actor explained that other regions have
experienced significant drop backs in ART initiation because of reagents for CD4 and blood
chemistry being out of stock, which was not the case in Shiselweni.

32
2.2.5 Programme monitoring
Some MOH coordinators were satisfied with the quality of programme monitoring systems.
Good monitoring of programme results and the impact of research on improved data
collection was identified as having had a positive impact on the quality of care:
“The monitoring system is working well. Data are more accurate, because doctors are really visiting
the places and are very interested in the data, which is not the case elsewhere. We learn from this
region and want to do the same in other regions.” (MOH)
MSF regional coordinators explained that regular data review meetings, organised at zonal
and regional level, also have proofed very useful in this respect.
An MOH representative mentioned the downside of the centralised HIV national
monitoring system, which implies that all data from the clinics are collected on paper and
transferred to electronic format only at the mother health facility level, and exclusively by
doctors. This creates a big bottle-neck with a backlog of data. In his opinion the monitoring
system should be decentralised to the clinics, like HIV and TB services themselves.
Having timely access to reliable HIV data from MOH sources apparently has been a
challenge for MSF as well, which was tried to be compensated by parallel data collection.
However, this has reportedly led to double efforts and lack of efficiency.
2.2.6 Community-based activities
There was a very positive overall perception of the different community-based activities,
implemented by MSF complementary to the decentralisation of HIV and TB care at primary
health care level. Among them are: 1) activities carried out by community expert clients
(health promotion, support groups for PLWHA, defaulter tracing, condom distribution), 2)
more recent mobile HIV testing and TB screening outreach44
with referral to health
facilities, 3) training of key community representatives (chiefs and other community
leaders, traditional healers, pastors, rural health motivators) and their involvement in
community mobilisation. All were described as having been very helpful in terms of
increasing the community knowledge about the disease, the benefit of testing and
treatment and the availability of health services:
“It has helped our community. They see things differently. Because now when they come to the clinic,
they know which services they will get, which treatment they can get in the clinic or hospital.” (Nurse
MOH)
Community expert clients hired by MSF are perceived as important players in linking the
community with the health facilities. They serve as role models in their community,
encourage people to go for HIV and TB testing and live positively with HIV. In the sight of
community leaders they have contributed to reducing the HIV related stigma and
discrimination through their work and open HIV status.
Some critical remarks were made by some MSF coordinators about the sustainability of
community expert clients. There are doubts if it would have been better to invest more in
capacity building of existing MOH supported rural health motivator network instead of
44
Partially in combination with mobile clinics with primary health care services, some providing ARV refill.

33
hiring a new workforce that might never be absorbed by the government system. On the
other side, motivation, education, age and acceptance of confidentiality were mentioned
as potential limitations of rural health motivators.
Mobile activities
HIV testing and TB screening – one of the more recent community-based strategies to
increase access to HIV and TB services – is appreciated by all the different groups of
informants. This is identified as a good strategy to particularly reach those who do not
access services at health facilities, i.e. men and groups at younger ages. Health workers
also confirmed that the referral of those who test positive to the health facilities works
well.
Mobile testing activities at special events or during mobile clinics are said to be quite
successful. However, MSF informants highlight that testing at strategic places targeting
specifically men45
are still not as high as expected. Door-to-door testing was therefore
suggested by an MSF coordinator and a regional MOH representative as a potentially more
effective and also more efficient strategy. Giving incentives for testing, as done by some
other organisations, was not found appropriate by MSF respondents.
Health promotion
Involving chiefs and other community leaders, traditional healers, religious leaders and
rural health motivators in health promotion and stigma reduction by training them,
consulting them and collaborating with them was perceived as a very powerful strategy in
the Swazi context since their influence is considered to be very high. A positive example of
a traditional healer under ART who disclosed publicly on World AIDS Day was mentioned in
this respect. Many informants suggested that this collaboration should be developed even
further. Some critically remarked that community leaders’ involvement should have been
stronger in the past.
“Working in depth with community is a strength of MSF in Shiselweni. The more we have a dialogue
with the community and decision makers in the community the more we are on the right track.” (MSF
coordinator)
Integration of TB in MSF community activities was appreciated by MOH and other national
and international actors. It was highlighted as being distinct from other organisations. This
focus, enhanced by MDR-TB home care, is perceived as “remarkable” by an international
actor and as a successful strategy to increase access and coverage.
All groups of informants felt that home care for MDR-TB patients, who need daily
injections during the intensive phase, was a good strategy as such. However, the
involvement of lay people (community treatment supporters) under supervision and
training by community nurses in giving MDR-TB injections at home is a real ‘opinion
splitter’.
MDR-TB patients, who had completed their intensive phase, were very positive about the
home care support and highlighted the relief it meant to them. This is consistent with the
45
Men regularly gather jointly for organised preventive treatment for their livestock at a community dip tank.
These regular gatherings are used as one of the strategic places to reach men in rural communities of
Shiselweni.

34
positive feedback of another study on the ambulatory MDR-TB care in Shiselweni.46
They
suggest that it would be even better if they could be former MDR-TB patients themselves.
“Injections make us very weak but it was good to have it at home unlike when you have to go to the
hospital.” (FG MDR-TB patients)
In addition, patients as well as health workers praise the home care as being holistic –
looking after patients’ physical and psychological wellbeing, side effects, adherence,
infection control in the homestead, education of family members, food and financial
support for monthly travel to the TB clinic in the mother health facility.
“(For) TB patients, who were taking the injection, MSF provided money so that everyday someone
would go there to inject them. It has been helpful. Patients used to default not because they do not
want to take those injections but too far or too weak.” (Expert client)
Other opinions ranged from this being the only feasible way to provide MDR-TB treatment
(MSF and some regional MOH) to scepticism (nurses, MOH, international actors) to clear
opposition (MOH).47
Many informants from the community didn’t know about the
community treatment supporters at all.
2.3 Programme outcomes and impact
Overall the decentralisation experience in Shiselweni regions was perceived as a great
success by all groups of interviewees. In the sight of all health sector representatives its
main objective of bringing diagnosis and care closer to patients has been fully achieved at
clinic level and partially at community level.
Great improvements have been highlighted in terms of access to HIV and TB care,
improved quality of care, increased coverage, reduced morbidity and mortality, retention
in HIV care, improved TB treatment outcomes as well as prevention of HIV and TB. In terms
of performance indicators Shiselweni has apparently turned from the worst performing to
the best performing region in the country.
From the patients’ and community perspective, tremendous changes are highlighted
notably in accessibility of services, stigma, improved health and reduced mortality:
“We’ve seen so many changes over the years and it is becoming better and better as each day
passes. This is mainly because we’ve seen people who were hopelessly ill but because of the medical
attention they got, they have recovered and are now healthy.” (FG patients)
46
Candidate Number 105302. Quantitative and qualitative analysis of ambulatory care for multidrug-
resistant tuberculosis patients in Swaziland: Clinical outcomes and patient experience. Master thesis. London
School for Tropical Medicine and Public Health, 2012. In the qualitative part of the study 8 out of 10 patients
interviewed were positive about their experience. One said that the community health worker’s injections
were more painful. In the other case the treatment supporter got infected with MDR-TB which caused social
problems between the families.
47
See ‘Acceptability of task shifting’ on page 28.

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