The scaling up of TB/HIV service delivery integration at the primary level health facilities in Tanzania: the assessment of health workforce readiness

Background: Tuberculosis (TB) remains the leading cause of morbidity and mortality in the individuals infected with Human Immunodeficiency Virus (HIV) in Tanzania. In 2013, 47.6% of the tuberculosis cases in Tanzania were HIV positive. Tanzania is also not on track to achieve the targets of decreasing TB/HIV co-infection despite the introduction of the TB/HIV integration policy guideline in 2008; and the availability of financial and technical support from global health initiatives. The scale up of activities in the TB/HIV integrated policy guideline remains challenging. The lack of health workforce readiness is among the major threats to successful implementation of TB/HIV integrated services at primary level health facilities. Thus, an effective readiness approach in the health workforce is needed to enable scale up of the integrated TB/HIV services at primary level in Tanzania. Objectives: Given the importance of scaling up integrated TB/HIV services in Tanzania, this thesis aims to understand how health workforce readiness in Low and Middle Income Countries (LMICs) can promote or hinder the scale up of integrated TB/HIV services at primary level health facilities. Methods: A desk-based review of the empirical research describing TB/HIV health services integration in a health system with a particular focus on the health workforce readiness. Results: Nineteen studies from ten LMICs met the inclusion criteria for review. The requirements from health workforce to respond effectively and take up the responsibility of TB/HIV service integration were categorized into factors related to training, cognition, compliance, availability, communication and support. In service training was the most critical requirement for health workforce readiness. The assessment of health workforce readiness revealed that support systems such as supervision, and a reliable health information system had a major effect in improving health workforce readiness. Insufficient infrastructure and lack of consumables in the single facility model at primary health facilities were the leading principal health system input obstacles to improving health workforce readiness. Importantly, the organizational readiness at the national, sub national and district levels effectively enhanced health workforce readiness in the single facility model. The coordination of TB/HIV integrated services; needs based planning; periodic health workforce sensitization; teamwork; and effective management were among organizational readiness factors that influenced health workforce readiness. Conclusion: Whereas health workforce readiness is critical to scale up integrated TB/HIV services in the LMICs, it is important to ascertain benchmarks for readiness that are essential to sustaining TB/HIV health services and translate to a reduction of TB/HIV co-infection in a local context. Key words: TB/HIV integration, health system, health workforce, readiness, LMICs and primary level health services.msc_gloheaunpub2321_ethesesunpu