Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organizational capacity in East, Central, and Southern Africa.

BACKGROUND: The African Health Professions Regulatory Collaborative (ARC) was launched in 2011 to support countries in East, Central, and Southern Africa to safely and sustainably expand HIV service delivery by nurses and midwives. While the World Health Organization recommended nurse initiated and managed antiretroviral therapy, many countries in this region had not updated their national regulations to ensure nurses and midwives were authorized and trained to provide essential HIV services. For four years, ARC awarded annual grants, convened regional meetings, and provided technical assistance to country teams of nursing and midwifery leaders to improve national regulations related to safe HIV service delivery. We examined the impact of the program on national regulations and the leadership and organizational capacity of country teams. METHODS: Data was collected to quantify the level of participation in ARC by each country (number of grants received, number of regional meetings attended, and amount of technical assistance received). The level of participation was analyzed according to two primary outcome measures: 1) changes in national regulations and 2) improvements in leadership and organizational capacity of country teams. Changes in national regulations were defined as advancement of one "stage" on a capability maturity model; nursing and midwifery leadership and organizational capacity was measured by a group survey at the end of the program. RESULTS: Seventeen countries participated in ARC between 2012 and 2016. Thirty-three grants were awarded; the majority addressed continuing professional development (20; 61%) and scopes of practice (6; 18%). Fourteen countries (representing approximately two-thirds of grants) progressed at least one stage on the capability maturity model. There were significant increases in all five domains of leadership and organizational capacity (p < 0.01). The number of grants (Kendall's tau = 0.56, p = 0.02), duration of technical assistance (Kendall's tau = 0.50, p = 0.03), and number of learning sessions attended (Kendall's tau = 0.46, p = 0.04) were significantly associated with improvements in in-country collaboration between nursing and midwifery organizations. CONCLUSIONS: The ARC program improved national nursing regulations in participating countries and increased reported leadership, organizational capacity, and collaboration among national nursing and midwifery organizations. These changes help ensure national policies and professional regulations underpin nurse initiated and managed treatment for people living with HIV.

Cross-sectional description of nursing and midwifery pre-service education accreditation in east, central, and southern Africa in 2013.

BACKGROUND: In 2013, the World Health Organization issued guidelines, Transforming and Scaling Up Health Professional Education and Training, to improve the quality and relevance of health professional pre-service education. Central to these guidelines was establishing and strengthening education accreditation systems. To establish what current accreditation systems were for nursing and midwifery education and highlight areas for strengthening these systems, a study was undertaken to document the pre-service accreditation policies, approaches, and practices in 16 African countries relative to the 2013 WHO guidelines. METHODS: This study utilized a cross-sectional group survey with a standardized questionnaire administered to a convenience sample of approximately 70 nursing and midwifery leaders from 16 countries in east, central, and southern Africa. Each national delegation completed one survey together, representing the responses for their country. RESULTS: Almost all countries in this study (15; 94%) mandated pre-service nursing education accreditation However, there was wide variation in who was responsible for accrediting programs. The percent of active programs accredited decreased by program level from 80% for doctorate programs to 62% for masters nursing to 50% for degree nursing to 35% for diploma nursing programs. The majority of countries indicated that accreditation processes were transparent (i.e., included stakeholder engagement (81%), self-assessment (100%), evaluation feedback (94%), and public disclosure (63%)) and that the processes were evaluated on a routine basis (69%). Over half of the countries (nine; 56%) reported limited financial resources as a barrier to increasing accreditation activities, and seven countries (44%) noted limited materials and technical expertise. CONCLUSION: In line with the 2013 WHO guidelines, there was a strong legal mandate for nursing education accreditation as compared to the global average of 50%. Accreditation levels were low in the programs that produce the majority of the nurses in this region and were higher in public programs than non-public programs. WHO guidelines for transparency and routine review were met more so than standards-based and independent accreditation processes. The new global strategy, Workforce 2030, has renewed the focus on accreditation and provides an opportunity to strengthen pre-service accreditation and ensure the production of a qualified and relevant nursing workforce.

Nursing and midwifery regulatory reform in east, central, and southern Africa: a survey of key stakeholders.

BACKGROUND: In sub-Saharan Africa, nurses and midwives provide expanded HIV services previously seen as the sole purview of physicians. Delegation of these functions often occurs informally by shifting or sharing of tasks and responsibilities. Normalizing these arrangements through regulatory and educational reform is crucial for the attainment of global health goals and the protection of practitioners and those whom they serve. Enacting appropriate changes in both regulation and education requires engagement of national regulatory bodies, but also key stakeholders such as government chief nursing officers (CNO), professional associations, and educators. The purpose of this research is to describe the perspectives and engagement of these stakeholders in advancing critical regulatory and educational reform in east, central, and southern Africa (ECSA). METHODS: We surveyed individuals from these three stakeholder groups with regard to task shifting and the challenges related to practice and education regulation reform. The survey used a convenience sample of nursing and midwifery leaders from countries in ECSA who convened on 28 February 2011, for a meeting of the African Health Profession Regulatory Collaborative. RESULTS: A total of 32 stakeholders from 13 ECSA countries participated in the survey. The majority (72%) reported task shifting is practiced in their countries; however only 57% reported their national regulations had been revised to incorporate additional professional roles and responsibilities. Stakeholders also reported different roles and levels of involvement with regard to nursing and midwifery regulation. The most frequently cited challenge impacting nursing and midwifery regulatory reform was the absence of capacity and resources needed to implement change. DISCUSSION: While guidelines on task shifting and recommendations on transforming health professional education exist, this study provides new evidence that countries in the ECSA region face obstacles to adapting their practice and education regulations accordingly. Stakeholders such as CNOs, nursing associations, and academicians have varied and complementary roles with regard to reforming professional practice and education regulation. CONCLUSION: This study provides information for effectively engaging leaders in regulatory reform by clarifying their roles, responsibilities, and activities regarding regulation overall as well as their specific perspectives on task shifting and pre-service reform.

The african health profession regulatory collaborative for nurses and midwives.

BACKGROUND: More than thirty-five sub-Saharan African countries have severe health workforce shortages. Many also struggle with a mismatch between the knowledge and competencies of health professionals and the needs of the populations they serve. Addressing these workforce challenges requires collaboration among health and education stakeholders and reform of health worker regulations. Health professional regulatory bodies, such as nursing and midwifery councils, have the mandate to reform regulations yet often do not have the resources or expertise to do so. In 2011, the United States of America Centers for Disease Control and Prevention began a four-year initiative to increase the collaboration among national stakeholders and help strengthen the capacity of health professional regulatory bodies to reform national regulatory frameworks. The initiative is called the African Health Regulatory Collaborative for Nurses and Midwives. This article describes the African Health Regulatory Collaborative for Nurses and Midwives and discusses its importance in implementing and sustaining national, regional, and global workforce initiatives. DISCUSSION: The African Health Profession Regulatory Collaborative for Nurses and Midwives convenes leaders responsible for regulation from 14 countries in East, Central and Southern Africa. It provides a high profile, south-to-south collaboration to assist countries in implementing joint approaches to problems affecting the health workforce. Implemented in partnership with Emory University, the Commonwealth Secretariat, and the East, Central and Southern African College of Nursing, this initiative also supports four to five countries per year in implementing locally-designed regulation improvement projects. Over time, the African Health Regulatory Collaborative for Nurses and Midwives will help to increase the regulatory capacity of health professional organizations and ultimately improve regulation and professional standards in this region of Africa. The African Health Regulatory Collaborative for Nurses and Midwives will measure the progress of country projects and conduct an annual evaluation of the initiative's regional impact, thereby contributing to the global evidence base of health workforce interventions. CONCLUSION: The African Health Regulatory Collaborative for Nurses and Midwives is designed to address priority needs in health workforce development and improve regulation of the health workforce. This model may assist others countries and regions facing similar workforce challenges.

Improved HIV and TB Knowledge and Competence Among Mid-level Providers in a Cluster-Randomized Trial of One-on-One Mentorship for Task Shifting.

INTRODUCTION: Health worker shortages pose a challenge to the scale up of HIV care and treatment in Uganda. Training mid-level providers (MLPs) in the provision of HIV and tuberculosis (TB) treatment can expand existing health workforce capacity and access to HIV services. METHODS: We conducted a cluster-randomized trial of on-site clinical mentorship for HIV and TB care at 10 health facilities in rural Uganda. Twenty MLPs at 5 randomly assigned to an intervention facilities received 8 hours a week of one-on-one mentorship, every 6 weeks over a 9-month period; and another 20 at 5 control facilities received no clinical mentorship. Enrolled MLPs' clinical knowledge and competence in management of HIV and TB was assessed using case scenarios and clinical observation at baseline and immediately after the 9-month intervention. The performance of the study health facilities on 8 TB and HIV care indicators was tracked over the 9-month period using facility patient records. RESULTS: Thirty-nine out 40 enrolled MLPs had case scenario and clinical observation scores for both the baseline and end of intervention assessments. Mentorship was associated with a mean score increase of 16.7% (95% confidence interval: 9.8 to 23.6, P < 0.001) for the case scenario assessments and 25.9% (95% confidence interval: 14.4 to 37.5, P < 0.001) for the clinical observations. On-site clinical mentorship was significantly associated with an overall improvement for 5 of the 8 health facility TB and HIV indicators tracked. CONCLUSIONS: One-on-one on-site mentorship improves individual knowledge and competence, has a downstream effect on facility performance, and is a simple approach to training MLPs for task shifting.

How Can the Health System Retain Women in HIV Treatment for a Lifetime? A Discrete Choice Experiment in Ethiopia and Mozambique.

INTRODUCTION: Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. METHODS: Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambézia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. RESULTS: 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. CONCLUSIONS: Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.

Developing a Continuing Professional Development Program to Improve Nursing Practice in Lesotho.

INTRODUCTION: In 2010, the Lesotho Ministry of Health and Social Welfare (MOHSW) issued the Continuing Education Strategy for all Health Care Workers in Lesotho, requiring professional regulatory bodies to enforce continuing education requirements amongst their members. In order to comply with this strategy, the Lesotho Nursing Council worked to develop a national comprehensive program for continuing professional development (CPD). METHODS: Through a seed grant and technical assistance from the African Health Professions Regulatory Collaborative (ARC), national nursing and midwifery leadership collaboratively developed a national CPD framework. The draft CPD framework and logbook were formally vetted with stakeholders during consultative meetings held around the country. ACHIEVEMENTS: The CPD framework was successfully piloted prior to being launched nationally in October 2012. This is the first health professional CPD program in Lesotho. Development of a CPD program in Lesotho has created a platform to reconcile nursing practice with the legislative standards governing the workforce. CHALLENGES: The one-year grant timeframe, along with limited financial and staff resources limited presented implementation challenges. CONCLUSION: In establishing a comprehensive national CPD program, it is critical for countries to engage in a staged planning process that includes monitoring and evaluation.

Development of a framework to measure health profession regulation strengthening.

This paper describes the development of a framework to evaluate the progress and impact of a multi-year US government initiative to strengthen nursing and midwifery professional regulation in sub-Saharan Africa. The framework was designed as a capability maturity model, which is a stepwise series of performance levels that describe the sophistication of processes necessary to achieve an organization's objectives. A model from the field of software design was adapted to comprise the key functions of a nursing and midwifery regulatory body and describe five stages of advancing each function. The framework was used to measure the progress of five countries that received direct assistance to strengthen regulations and to benchmark the status of regulations in the 17 countries participating in the initiative. The framework captured meaningful advancements in regulatory strengthening in the five supported countries and the level of regulatory capacity in participating countries. The project uses the framework to assess yearly progress of supported countries, track the overall impact of the project on national and regional nursing regulation, and to identify national and regional priorities for regulatory strengthening. It is the first of its kind to document and measure progress toward sustainably strengthening nursing and midwifery regulation in Africa.

A survey of nurse-initiated and -managed antiretroviral therapy (NIMART) in practice, education, policy, and regulation in east, central, and southern Africa.

In sub-Saharan Africa, nurses and midwives perform many HIV service delivery tasks, such as diagnosis of HIV and prescription of antiretroviral therapy (ART), which used to be the responsibility of physicians. While this task shifting is critical to scaling-up HIV services in Africa, the extent of HIV task shifting is not well understood. A survey of senior nursing leadership teams from 15 African countries was carried out to describe the extent of nurse-initiated and -managed antiretroviral therapy (NIMART) in practice, education, policy, and regulation. The survey took place at the African Health Professions Regulatory Collaborative meeting in Pretoria, South Africa, in June 2012. The findings indicated that NIMART is widely practiced and authorized in policy, but is not reinforced by regulation nor incorporated into preservice education. Further investment in policy, regulation, and pre-service education is needed to ensure sustainable, high quality ART service expansion through the region.

The African Health Profession Regulatory Collaborative (ARC) at two years.

BACKGROUND: The African Health Profession Regulatory Collaborative (ARC) for nurses and midwives was created in response to the increasing reliance on shifting HIV tasks to nurses and midwives without the necessary regulation supporting this enhanced professional role. ARC. APPROACH: The ARC initiative comprises regional meetings, technical assistance, and regulatory improvement grants which enhance HIV service delivery by nurses and midwives, and systematic evaluation of project impact. RESULTS: Eight of 11 countries funded by ARC advanced a full stage in regulatory capacity during their 1-year project period. Countries in ARC also demonstrated increased capacity in project management and proposal writing. DISCUSSION: The progress of country teams thus far suggests ARC is a successful model for regulation strengthening and capacity building, as well as presenting a novel approach for sustainability and country ownership. The ARC platform has been a successful vehicle for regional harmonisation of updated regulations and promises to help facilitate the enhancement of HIV service delivery by nurses and midwives.

Nursing and midwifery regulation and HIV scale-up: establishing a baseline in East, Central and Southern Africa.

INTRODUCTION: Shifting HIV treatment tasks from physicians to nurses and midwives is essential to scaling-up HIV services in sub-Saharan Africa. Updating nursing and midwifery regulations to include task shifting and pre-service education reform can help facilitate reaching new HIV targets. Donor-supported initiatives to update nursing and midwifery regulations are increasing. However, there are gaps in our knowledge of current practice and education regulations and a lack of information to target and implement regulation strengthening efforts. We conducted a survey of national nursing and midwifery councils to describe current nursing and midwifery regulations in 13 African countries. METHODS: A 30-item survey was administered to a convenience sample of 13 national nursing and midwifery regulatory body leaders in attendance at the PEPFAR-supported African Health Profession Regulatory Collaborative meeting in Nairobi, Kenya on 28 February, 2011. The survey contained questions on task shifting and regulations such as registration, licensure, scope of practice, pre-service education accreditation, continuing professional development and use of international guidelines. Survey data were analyzed to present country-level, comparative and regional findings. RESULTS: Task shifting to nurses and midwives was reported in 11 of the 13 countries. Eight countries updated their scope of practice within the last five years; only one reported their regulations to reflect task shifting. Countries vary with regard to licensure, pre-service accreditation and continuing professional development regulations in place. There was no consistency in terms of what standards were used to design national practice and education regulations. DISCUSSION: Many opportunities exist to assist countries to modernise regulations to incorporate important advancements from task shifting and pre-service reform. Appropriate, revised regulations can help sustain successful health workforce strategies and contribute to further scale-up HIV services and other global health priorities. CONCLUSIONS: This study provides fundamental information from which to articulate goals and to measure the impact of regulation strengthening efforts.