Box 10.5 : Key implementation considerations for programme managers: decentralizing ART services (section 9.4.3: Decentralizing HIV treatment and care)
Consolidated ARV guidelines, June 2013
Examine the models and options. Programmes should determine which clinical and laboratory services will be available at what level of the health care delivery system. The optimal model for ART decentralization (partial or full) depends on the local context.
Consider human resources policies and task shifting. All health workers, including community health workers, need to be trained regularly, mentored and supervised to ensure high-quality care and implementation of updated national recommendations. In many settings, decentralizing ART requires task shifting to ensure an appropriate mix of health workers at peripheral facilities. An appropriate regulatory framework (laws, regulations, policies and guidelines) is needed to allow tasks to be performed by different cadres of health workers, in addition to nationally standardized training, mentoring and supervision for all health workers involved in HIV care.
Implement strategies for retaining staff. Programme managers should support the development and implementation of policies to create a suitable environment for recruiting, retaining and motivating personnel in rural or remote areas, where health worker turnover and attrition may be considerably higher than in urban settings.
Strengthen linkages and referral systems. Although community-based treatment programmes provide an important option for decentralizing ART, they should always be linked with regular care at health facilities and with adequate laboratory, diagnostics, monitoring and evaluation and drug and supply management systems.
Agree on a division of labour. An efficient division of responsibilities among levels of the health system (national, provincial or regional and district) is crucial to minimize duplication and to optimize the use of resources. The role of each level should match its capacity, and the lines of authority and accountability should be clear and well understood by all.
Build partnerships. National regulatory bodies, professional associations and other stakeholders need to be involved when addressing the scope of practice, roles and responsibilities of health workers.