Data was synthesized from all the different qualitative methods employed, the results shed light on the difficulties faced in instigating task shifting policy. The health policy triangle (see Figure ) is used to graphically illustrate and structure the findings. The findings are thus presented against the four areas in the triangle: 'context', 'actors', 'process' and 'content'.
Context of VCT scale up in Kenya
In late 2000 a consultative meeting [19
] on VCT set the agenda for scale up, outlined government strategy and reviewed the results of pilot studies conducted in Kenya [33
] as well as experience with rapid testing from elsewhere. Key to the discussion was the availability of new rapid testing technologies. These were easy to conduct by lay people, meaning that specialised laboratory training was not necessary, did not require electricity or external reagents and gave results in 15 minutes, thus enabling the giving of results immediately after testing. In 2001 a national taskforce convened to oversee VCT services in Kenya. From the outset it intended to actively promote task shifting such that the burden of extra work created by HIV counselling and testing was distributed throughout the different categories of staff and maximum benefit was gained from the use of lay counsellors. With this in mind a new combined role, designated 'VCT counsellor', was conceived and a unified curriculum for training was published by the National AIDS and STD Control Programme (NASCOP). This covered counselling skills, rapid HIV testing using whole blood and quality assurance [34
]. It was open to health care professionals as well as lay counsellors.
Over 2500 VCT counsellors were trained and certified and 900 new sites opened in the following six years. The majority (80%) of these VCT sites were located in government health facilities. At the same time HIV testing in clinical settings was increasing in Kenya with antenatal clinics and hospitals incorporating provider-initiated HIV testing and counselling (PITC) as a routine standard of care. Health facilities trying to find ways to provide HIV counselling and testing in addition to their existing clinical services were experiencing significant new human resource challenges.
Key actors and their interests in task shifting
Table contains a summary of the key actors and their interests in task shifting. The strategic alliance between donors (who did not support salaries for government staff) and the central Ministry of Health (who were not in a position to hire new staff) was instrumental in encouraging task shifting.
Key actors and their potential impact on task shifting policy
"We have had a non-replacement policy within the hospitals and within most of the MoH now for years. At this point it is impossible for a major redirection of health personnel into VCT." (Male donor, key informant interview.)
The VCT taskforce was established with donor funding for initial meetings under MoH leadership in late 2000 and was convened by NASCOP. While the backbone of membership was MoH officials, donors and their implementing partners, a number of technical advisors, laboratory and counselling experts with experience in HIV testing and other key stakeholders were invited to attend either from the onset or at various stages over the course of the next few years (seen in the first column of table ). The inclusion of individuals with experience at the district level allowed human resource lessons, pilot studies and operational research to shape policy development.
Professional associations were also influential, but had a potential to undermine moves towards task shifting. Traditionally, both laboratory and counselling associations have been involved in HIV testing and counselling. Both expressed concerns that scale up and task shifting might compromise quality. The two associations looked at quality from two different angles. Whereas the counselling association did not mind lay counsellors conducting the testing, they were concerned over the length and content of the counselling training. On the other hand, the laboratory association were less concerned with this and more opposed to lay counsellors conducting testing. Laboratory operations are regulated by the Kenya Medical Laboratory Technicians and Technologists Board under an Act of Parliament and personnel may join the Association of Kenya Medical Laboratory Scientific Officers [35
] that acted as advocates for its members, rather like a union [36
]. Initial taskforce meetings agreeing the VCT guidelines included a number of laboratory professionals who were members, but not official representatives, of the board and association. Like many cadres of health professionals in Kenya there are a significant number of unemployed laboratory staff, as well as an employment embargo, which according to some was imposed by the International Monetary Fund [37
]. The association did not see the use of task shifting as being in the best interests of it members, the majority of whom saw HIV testing as the prerogative of laboratory technicians and technologists. They referred to the VCT guidelines, which state that they should conduct testing where available
, to reinforce their arguments.
"it rightly belongs to the lab people to test." (Laboratory technologist, key informant interview.)
The government does not currently recognize the counselling profession as a cadre in the MoH. As well as theory-based university courses in counselling psychology there are many registered counselling organisations. Two large associations of professional counsellors undertake generic training to certificate, higher diploma and Master's level. These organisations saw HIV testing as an opportunity to promote counselling as a profession. They underscored its central role in HIV services and encouraged members to learn how to conduct rapid testing. Once happy with the move to rename the new trainees as 'VCT counsellors' as distinct from 'professional counsellors' the associations shared training curricula with the national committee, took part in the process of developing a unified curriculum and encouraged as many as possible to attend their own or other recognised VCT counsellor training courses, whilst trying to maintain prime position in this market.
A number of large international non-governmental organisations and smaller local organizations, funded by donors, were involved in the provision of VCT services or technical support including procurement, logistics, counselling and testing and social marketing. Some were tasked by their donors to work with government staff, whilst others provided independent services. Donor policies generally restricted direct salary support to government staff but organisations were able to give technical and quality support. A number of the smaller organisations established mechanisms for donor funds to be routed through NGOs most of whom also had a vested interest in sustaining their own funds. The relationship between donors as taskforce drivers who promoted the scale up of lay counsellors and concerns around sustainability were openly debated in Kenya, where donors had high expectations of the speed of scale up and pushed the lay counsellor agenda from early on without formal assessment of longer-term sustainability (see table ).
Processes in task shifting
The process of reaching consensus on task shifting sufficient for the publication of unified national guidelines and curriculum involved lengthy discussions. The taskforce took a number of pragmatic early decisions based on the results of a pilot study [39
]. They were: to use health professionals selected from all cadres already on the government pay roll, to come up with a uniform training curriculum and to allow non-laboratory staff to conduct testing.
The development of the training manual for VCT counsellors was a contentious issue in the VCT taskforce and between counselling organisations, the MoH, international agencies and technical advisors (subcommittee minutes 2001). The development of the manual to the satisfaction of all parties with different views took almost two years to complete. There was disagreement on the length of training, counselling organizations wanted longer training, government agreed to a two-week training and some technical and donor agencies pushed for two-day training on testing alone. The last two groups were concerned that time away from service provision for training would exacerbate existing shortages. There was also disagreement on the content of counselling. The professional counsellors were pushing for a training that was grounded in counselling theories leaving them able to conduct fully client-centred therapeutic sessions. Others argued for an approach that was still client-centred but focused on exploring individual HIV risk issues and others still wanted a simplified training that taught counselling through providing trainees with lists of statements and questions on pre-printed cards that were to be used to guide the sessions. The disparate elements, content, curricula and theories of adult education were brought together in a participatory process and a manual was published in 2002.
Acrimonious debates in the taskforce (recurring theme in taskforce minutes Nov 2000 - Sept 2003) dominated the decisions on whether health workers (primarily nurses) or counsellors should provide the counselling and testing. Some committee members argued that it was wrong to divert health workers from clinical duties; others argued that medical diagnoses should remain the prerogative of clinicians and HIV testing the prerogative of laboratory technicians and technologists (diary notes, March 7-9th, 2001; Guidelines Retreat). There has been an evolution over time in response to these concerns. Initially health workers provided VCT services delivered in health facilities, and lay or non-medical counsellors provided services in stand-alone or community sites. By 2005 lay counsellors were employed to work as VCT counsellors in health facilities but government funding for these finished in 2009. By 2011, few remained in place. Instead health workers provide HIV testing and counselling as part of 'provider-initiated testing and counselling' (PITC) in health facilities and lay counsellors are employed in stand-alone VCT sites, mobile, outreach and door-to-door HIV testing and counselling programmes. Senior laboratory staff who have been on a training course train and certify VCT counsellors in HIV rapid testing, supervise the VCT counsellors doing testing and support the district medical laboratory in-charges to provide quality assurance mechanisms in VCT sites. In the end, the agreed wording for the guidelines was:
"All HIV testing for VCT should be done by laboratory technologists or technicians. However, in some locations and settings this is not possible. If they have successfully completed an accredited training in testing procedures and are supervised by a laboratory technologist/technician, other health workers may perform simple rapid tests for VCT purposes."
Practically however, only a proportion of testing was conducted by laboratory personnel. A few large stand-alone sites were able to hire one technician or technologist, but most sites, including health facilities, were conducting in-room testing by health care workers (participant observation, diary notes Nov 21st 2001). Some time after VCT was well established in the country, the issue was brought to the attention of the central MoH who tried to placate both sides, changing the wording of the guidelines to add 'or any other person authorised by the Minister of Health'.
"because the government has supported VCT scale up knowing that we don't have enough lab people to cope." (Female programme officer, Nairobi, KII.)
At the Annual Conference of Laboratory Scientific Officers in Kakamega in October 2002, data from implementing partners VCT sites were presented that confirmed that lay counsellors who conducted testing were getting a 99.6% level of accuracy according to rigorous external quality assurance [40
]. Despite this and due in part to a lack of clear statement from leadership, the dispute continued to rage. Variously described in interviews as a 'turf war'
a 'threat to professionalism'
and 'a concern over quality standards'
, the deliberations over who should conduct testing almost brought VCT scale up to a halt and reached the press in August 2003 with articles raising quality concerns about non-laboratory personnel testing. Popular daily national papers including the Nation, Standard and East African carried almost daily articles on the debate with headings such as 'Sincerity Lacking in VCTs', 'The Big Issue: Panic over HIV testing'; 'Fix it now, VCT debate getting out of control' and 'Government defends VCTs' (Figure ). The debate was intended to air the concerns of the Association about the professional erosion of the laboratory staff but actually gave a platform for donors to sponsor articles explaining quality assurance procedures and stimulated public interest in VCT sites.
Sample VCT newspaper headlines August and September 2003.
Despite this the conflict was barely noticed outside Nairobi. In fact some of the district and provincial interviewees thought the bad publicity may have stimulated interest in VCT. Most had good working relationships between the routine laboratory staff and VCT.
"At national level there has been a lot of politics but in our area so far no problem." (District Medical Officer of Health, KII.)
The laboratory members interviewed would have welcomed their inclusion in planning, in study design to evaluate quality, and in early stages of roll-out. The omission of the official representatives of the professional association and senior laboratory personnel working with the government was felt to be an error. However, there were still those who felt that an early official lab presence may have inhibited scale up in the public sector.
"If they were on the taskforce earlier it might have affected scale up. Depending on how strong they were or how forceful of their point of view it could have blocked expansion." (Female, donor, KII.)
Content of task shifting
The initial strategies for VCT scale up did not make task shifting policies for VCT explicit. Assumptions were made that health care workers, taken from a number of different cadres, would perform dual roles.
"VCT are manned from all directions. Some are public health technicians, some are nurses etc." (Male, programme officer, KII.)
There was an awareness that similar HIV counselling programmes had failed in the past due to the impact of dual roles (doing counselling as well as nursing) on provider stress, high attrition rates and inconsistent service delivery. This led to deliberate policies on the prevention of counsellor burn out through a policy of mandatory attendance at support supervision sessions. Furthermore lay personnel and 'volunteer counsellors' were encouraged to apply for training positions and to provide services with NGO support. Despite efforts to mitigate the impact of task shifting on strained resources, concerns arose not only about the lack of deliberate policy but also about the lack of clear line management structures that ensued. Staff reported to - and were evaluated by - their former bosses in their main discipline, many of whom were not versed in the expectations or job descriptions for VCT counsellors. This created tensions. For example, counsellors were told to see a max of 8-15 clients per day. A departmental head who had over 50 patients waiting to be served in another department by one nurse/midwife could not understand why someone would serve only 8 or 15 clients. Those who tried to perform both roles were frustrated and overworked. This resulted in internal conflict or frustrated clients as VCT service opening times became irregular in order to fit round other work expectations.
Subsequently the lack of promotional structures and of recognition for counselling as a cadre threatened the task shifting policies as far as the use of other health professionals was concerned and increasingly opened the door for lay counsellors to provide services in health facilities.
On the other hand, policies around quality assurance were integral to the scale-up strategy in Kenya [18
] and were central in guiding how to task shift to lay counsellors, many of whom were volunteers. The guidelines and training curriculum became a key element of the subsequent site registration and quality assurance systems. Within a year of the establishment of the taskforce, the guidelines had been disseminated throughout Kenya and an enforced registration system meant that all VCT sites should be operating under the same standards (Report on piloting of registration system VCT taskforce minutes Nov 7th 2001)
. Only registered sites could access the free HIV test kits funded by a World Bank loan [41
] in exchange for data on client uptake. A national data form was developed and registered sites completed a form for each individual.
"The government took a loan from the World Bank for the purchase of test kits. It helped us. Free kits probably accelerated the process and allowed us to control it." (Male MoH taskforce member, KII.)
The registration system then formed the basis of a comprehensive quality assurance programme that included supervision of counselling and testing, continuing education, laboratory-based testing using dried blood spots and inspection of sites. In late 2003 a National Quality Assurance Team was established, including laboratory supervisory staff, who visited all sites annually. The team found high standards of testing in registered sites [40
] and reported high client confidence in the approach used.
"It is important for the client and the counsellor to do their thing together and for the client to watch. Then clients have absolute confidence in their results." (Male, laboratory, KII.)