Impact of human resources on attempts to integrate TB and HIV care in developing countries

As the other posters to this blog know, I have been living in Johannesburg, South Africa since August. I came here to work on research on improved integration of TB and HIV care in various settings.

One of my studies is on TB screening in antenatal clinics that deliver prevention of mother to child transmission of HIV services. Rather than argue why this should be done, I'll post the slides from my presentation at the Stop TB Partners' Forum in Rio de Janeiro last week (https://jshare.johnshopkins.edu:443/cgounde1/StopTBPartnersForum_CGounder_20090324_abbrv.pdf). There's a clear case to be made. What isn't tough to answer is whether we do this. What is tough is to figure out is how to get staff buy-in.

The staff of the antenatal clinics includes both nurses and lay counselors. Before my study started, I trained the staff for 6 weeks on why TB was a problem among pregnant woman and neonates, and on how to do the study. I tried to inspire them to take ownership of their patients' care, and of the care of their communities.

Before the study started, the staff revolted and ask for a raise to compensate them for the additional work of the TB study. What eventually came out was that a year earlier, the staff had been given a raise to do TB screening in antenatal clinics, but had not done so until the TB study was going to require it of them.

So the staff began to work on the study... and I have been amazed by how much we have gotten done over the past couple months. They have been a pleasure to work with. At least that was until their boss resigned and a new Program Manager started a week ago. So now they are starting all over again, demanding a raise, refusing to do TB-related activities, threatening to quit. Nevermind that everyone in the research unit got a 10% raise last week.

I could of course give everyone working on the study a bonus (if I had the extra funding available to me), but this would set a bad precedent for future attempts to integrate TB and HIV activities in the future. TB and HIV activities should be integrated, but there isn't necessarily funding available to support this goal. So how does one do it? By offering bonuses through a study, I would further weaken ability of public health programs to negotiate with and retain staff when new or additional tasks are required of existing healthcare staff.

I sympathize with the staff... they are underpaid and struggle to get by. But at the same time, their patients are suffering even more.