1. Contact your district health office to learn the positions (number and cadre) assigned to your health centre

• How does the number and cadre of positions actually assigned compare with recommended staffing (see next page)?
• Are any assigned positions unfilled at your health centre? If so, how many?
• Which positions are vacant, and for how long have they been vacant?

The chart below presents the “basic” staffing recommended by your ministry of health

“Basic” staffing refers to staff required to provide primary care services not including chronic HIV care for PLHIV, and is based on the population served. Fill any vacant “basic staffing” positions first.

Adapt these staffing recommendations to your local situation. If you have a larger catchment population, add more staff. If you have an additional number of patients during some periods of the year, such as during malaria or harvest seasons, add more staff during these seasons, or make sure your staff does not take leave during these peak periods.

The chart below presents the “additional” staffing recommended by your ministry of health to provide HIV prevention, care, and treatment services at your health centre

If you provide HIV services, you should add the “additional” staff below to your “basic” staffing above.

2. Locate job descriptions for each position assigned to your health centre

Job descriptions will help you determine the qualifications and positions for staff you wish to recruit to your health centre. These job descriptions are usually standardized across health facilities, and should be on file at your health centre or at your district health office. Once staff are hired, job descriptions can be used to help assess employee performance.

3. Learn how the local hiring process works

Hiring is usually carried out by the district health office, but you can increase your odds of obtaining the staff you need by: being informed about the hiring procedures that apply to your health centre, advocating for your team, and pursuing alternative hiring procedures when needed. For example, you may need to send an official request to the head of your district health services, who will approach the district personnel office to create a position or fill the vacancy. In some cases, the recruitment has to go via district authorities to the ministry of health and ministry of public service. Once the position and its budget have been approved, the district service commission or an equivalent body can advertise it, form a selection committee, and recruit candidates.

4. Try to ensure that you are on the selection committee

Being on the selection committee gives you a chance to help choose who will be hired at your health centre. Contact your district health office to make this request.

5. Communicate regularly with the local recruiting authorities

Keep in contact with people in the personnel office at your district health office so that you know of upcoming changes that could affect staffing of positions at your health centre. Keep these people informed of your staffing needs, using the information you gathered, and citing the vacancies that exist and the recommended staffing tables above to justify your need for additional staff.

6. Be persistent!

If budget ceilings or other limitations prevent you from hiring staff:

• Ask to hire staff on temporary contracts.
• Try alternative procedures. Contact local NGOs and donors to ask if they can hire and pay the salaries for new staff at your health centre.
• Recruit volunteers. Make sure you develop good relations with local communities and community groups so you can recruit volunteers in times of high workload (see below).

7. Recruit lay providers for your health centre team, including PLHIV

Recruiting lay providers can help increase the number of staff at your health centre. Lay providers are non-professional workers who can serve as counsellors, triage officers, data clerks, community health workers, nursing, laboratory and pharmacy assistants, and more. Depending on their training and experience, lay providers can work in non-clinical and clinical roles as paid staff or volunteers. See examples of how to include lay providers in the health centre team at the end of this section.

You should encourage people living with HIV (PLHIV) to apply for lay provider positions because they bring unique skills to your team. PLHIV have personal experience with the disease, and can help other patients to understand and use the health system, address personal and family issues (such as stigma and HIV disclosure), and manage treatment and its side-effects. Indeed, PLHIV are valued members who can occupy all levels in the health centre team, from medical officer to lay provider.

In order to encourage the participation of lay providers, including PLHIV, at health centres you can:

Identify the tasks that could be performed by lay providers

Lay providers can perform a range of tasks including helping with triage, taking patients' vital signs and pulling their charts, data keeping, treatment adherence counselling, treatment literacy and education. They can also do pill counting and stock management, track patients who are lost to follow-up, community outreach, home-based care and follow-up, manage PLHIV support groups, handle counselling (such as for people who are HIV-positive and their partners), basic laboratory testing, and more.

Make sure that lay providers taking on new tasks are closely supervised, mentored and supported by experienced health centre staff

For example, if lay providers are performing HIV counselling and testing, the health centre nurse needs to establish regular meeting times with them so she/he can observe, supervise, and act as a mentor to that person.

Identify the health centre provider's ‘clinical back-up’ at district level and make sure they have regular communications with this back-up staff

Health centre providers need district counterparts who will supervise and act as their mentors, and who will ensure that patients are being adequately referred to the district and are returning to the health centre for services. For example, nurses handling ART and follow-up need to have regular communications with the district medical officer or head clinician. This will ensure that referrals are made correctly for patients with complications and that consultations take place on challenging cases. “Back-up” at district level is also needed for laboratory, pharmacy, and supply management staff.

Establish a clinical “team-based approach” through regular clinical team meetings and good communications between staff

Conduct a weekly meeting of all staff at which you can openly discuss patient cases and issues that arise, and work together to solve problems. Encourage regular dialogue between staff about how to improve tasks to increase service efficiency and quality.

Establish regular performance measurements to assure adherence to clinical and other standards (see Quality Improvement chapter)

Implement strategies to motivate your staff and to prevent ‘burnout’

When staff are required to take on new tasks in an already heavy workload, they can suffer increased anxiety, stress and burnout. Work together as a team to determine how you can keep each other motivated. Section 9.6 on ‘employee motivation’ provides some tips.

Task shifting can be a real asset to your health centre, but it takes teamwork, supervision and constant communication!

Keep a training log

The in-charge should make sure a training log is created and updated for every training session that an employee receives. A log can take any form, but should include the name and position of the staff who received the training (e.g. nurse, pharmacist, etc.), name of the training course, the provider of the training (organization or government office) and the date the course occurred. A data clerk can be responsible for filling out the log, but a supervisor will need to make sure this is done on a regular basis and that the log is up to date. Annex 9.2 of this manual includes training log samples you can use.

RECOMMENDED TRAINING

To provide basic primary care services, the following training is recommended:

To provide HIV prevention, care, and treatment, the following additional training is recommended

Clinical mentoring

A clinical mentor is a clinician with experience and expertise who provides ongoing training and advice to clinical providers with less experience or expertise. The goal is to help the less experienced provider develop skills and experience, grow professionally, and provide higher quality care. Mentors meet regularly with the providers they are helping to review clinical cases, answer questions, problem-solve, and provide feedback and assist with case management. Mentors can be formally assigned to a staff member or they can volunteer based on their personal interest.

A clinical mentor is different from a supervisor, who has formal authority over a staff member and is responsible for evaluating performance. Mentors are instead more like a ‘coach’, who focuses on improving staff expertise, motivation and confidence. Clinical mentors should be supportive of the staff person and their growth as a person and a professional.

In a network model of care, clinical mentoring at the heath centre will be conducted through visits by clinical providers from the district hospital, and through ongoing phone and e-mail correspondence where available.

What you should know about clinical mentoring visits

When a primary health centre begins providing chronic HIV care and treatment, it will require one mentoring visit from a district hospital clinical provider every month for the first six months. After six months, the health centre will require only one visit every two to three months. If you are not receiving this level of mentoring, contact your district health office.

Each mentoring visit takes at least one day, but frequently may take three to four days.

Clinical mentoring visits usually include:

• observation of case management and reinforcement of a staff member's skills;
• review of patient monitoring cards and Pre-ART and ART registers;
• clinical case review;
• clinical team meeting;
• documentation of each visit (including recommendations).
• your health centre clinical team should prepare for these visits by reserving the dates and selecting patient cases for review (such as cases of people recently initiated into antiretroviral therapy, as well as routine, challenging or difficult cases, or deaths). In some instances, inviting the patient back to the clinic when the clinical mentor is scheduled to be there can facilitate consultation and avoid referral.
• integrate the recommendations of your mentor into quality management/improvement activities at your health centre.

Supervision

Supervision is a formal relationship of authority between a more senior ranking health worker and his or her subordinates. Supervisors can be located at the primary health centre or at a higher level facility such as the district hospital. A health centre supervisor is responsible for helping ensure that each staff member is providing adequate service delivery and is following health centre rules and policies. The following chart outlines recommended supervision at your primary health centre:

Effective supervision is especially important to provide quality HIV services. Chronic HIV care and treatment requires health workers to undertake continuous learning and to be able to solve problems. Those demand regular consultations with an engaged and supportive supervisor.

Supportive Supervision

Supervision does not mean finding ‘fault’ with your staff's work. Instead, supportive supervisors focus on making sure their staff has the training, mentoring, guidelines and tools, equipment and supplies and working conditions they need to perform the job effectively. It means assisting your junior staff to achieve goals, identify problems and challenges and together find solutions to problems. The supervisory relationship should be compassionate, supportive and helpful. Good supervisors learn from their subordinates, adapt to their needs and should be open to suggestions.

Prevent and manage workplace exposure to HIV

During employee training, workplace procedures that deal with exposure to HIV should be included with other workplace safety guidelines, and be monitored regularly to assure they are implemented. Even after you take measures to prevent workplace exposure to HIV, you should be prepared for it to occur. Below are some steps you should take to minimize HIV exposure in the workplace:

1. Identify a contact person to deal with workplace HIV exposure.

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   Choose someone who is:

   Responsibilities:

   responsible trained trusted and agreed on by health centre staff available during all working hours (or assign more than one contact person).

   explaining procedures and PEP coordinating blood results arranging confidential HIV testing and post-test counselling for the health worker remind the health worker when follow-up blood tests are due completing the necessary forms and reports ensuring confidential storage of all documentation completing the incident report (for occupational health and safety review and for possible compensation) and include in health centre log book

2. Set up a system to urgently respond to workplace HIV exposure and make HIV-PEP available 24 hours a day/seven days a week.
3. On the wall of your clinic, post the PEP procedures – available as a wall poster in Annex 9.3 of this manual – and make PEP clinical guidelines easy to obtain at all times.
4. Keep starter packs – or initial doses of PEP – in the health centre emergency cupboard and ensure that they are accessible 24 hours a day including during holidays and weekends. Workers should have the option to obtain services away from the worksite in order to increase privacy and confidentiality
5. Encourage staff to report incidents of exposure to HIV in the workplace. Use the HIV-PEP procedures for ALL staff exposed to HIV in the workplace (this means all categories of health personnel, including public and private employees).
6. Routinely inform health personnel about HIV-PEP. This includes how and where to obtain advice, and reporting procedures during working hours.
7. Support health worker access to confidential HIV counselling and testing services.

Facilitate health worker HIV testing, counselling, HIV care and ART

• Encourage every member of your staff – including auxiliary staff and volunteers – to be tested.
• Place information in staff rooms about local locations of confidential HIV counselling and testing and care and treatment services.
• Make sure health workers understand that unprotected sex remains the most common route of HIV transmission; emphasize that safer sex practises are very important.
• Health workers should understand the importance of starting ART early.
• Support the formation of HIV-positive health-worker support groups.
• Ensure health workers have access to confidential and low-or no-cost HIV care and treatment.

Combat workplace stigma about HIV and TB

• Staff are often afraid to be tested or receive treatment for fear of being rejected by others at work.
• Develop an HIV and TB workplace policy/plan (your district health office can help you).
• Hang posters with messages that combat stigma.
• Communicate with your staff regularly about having positive attitudes towards people living with HIV.
• Invite a PLHIV community group to visit your health centre during a regular staff meeting to discuss their experiences with HIV-related stigma and how being HIV-positive affects a person's life.

Protect health workers from TB

• Ensure TB infection control throughout the health centre. This protects both health workers and patients. See chapter 5, infection control guidelines in Infrastructure.

In addition, all health workers should

• know the signs and symptoms of TB disease;
• be supported to know their HIV status. Those with HIV infection should be given the opportunity to minimize their exposure to people who have TB disease;
• be offered INH prophylaxis if they have a positive tuberculin test or are HIV-infected after excluding TB disease (see clinical guidelines).

Protecting health workers against stress and burnout

• Recognize burnout! Symptoms include irritability, anger, poor sleep patterns, inadequate concentration, avoidance of patients and problems, withdrawal from others, fatigue, emotional numbing including lack of pleasure; resorting to alcohol or drugs; and (in survivors of multiple loss) fear of grieving.
• Be confident that you have the skills and resources to care for the patient and their family.
• Define for yourself what is meaningful and valued in caregiving.
• Encourage staff to discuss problems with someone. Share problems with your colleagues; consider forming a staff support group.
• Include in your week a time to discuss patients with other staff (at staff meetings, case reviews).
• Be aware of what causes stress and avoid it.
• Use strategies that focus on problems rather than emotions.
• Change your approach to caregiving: divide tasks into manageable parts (small acts of care); learn how to adjust the pace of caregiving; ask others to help; encourage self-care by the patient.
• Use relaxation techniques.
• Take care of your life outside of your caregiving (ensure you have other interests, family, friends).
• Develop your own psychosocial support network (such as care-giver support groups).
• Take care of your own health.
• Take time off on a regular basis.
• Be aware that you cannot do everything and that you need assistance.
• Organize or participate in social events (staff birthdays, marriages or graduations, etc.).

Promote safe injections (protect against HIV and hepatitis transmission)

• Do not give injections unless they are necessary. Use oral medications in cases where they are recommended.
• Give injections with single-use or adequately sterilized equipment.
• Do not recap needles.
• Discard used needles and syringes immediately in sharps container.
• Close, seal and send sharps containers for incineration before they are completely full (follow your facility protocol carefully) – see chapter 5, Infrastructure.

Supplies and procedures to support other standard precautions¹

How can I grow while on my job?

Each staff member needs opportunities to grow and develop, such as participating in training, mentorship, new tasks, and chances to be promoted to a more senior level.

• Achievement is important. Help your staff achieve success in their position through giving them positive feedback, ideas, and advice on how to improve their performance.
• Do not micro-manage! Your staff is more motivated to work when they are involved in decision-making and have responsibility. Allow your staff to make more decisions and handle additional responsibilities over time. If they make a mistake, help them learn from it and improve.
• Advancement is a form of recognition. Encourage people to learn and increase their knowledge and skills for self-advancement and promotion. Ensure that your staff knows about and pursues existing continuing education, on-the-job training and in-service education opportunities.
• Support new ideas and creative initiatives in the workplace. These opportunities help your staff to develop personally and professionally.

Am I being treated fairly?

Every employee needs to feel a sense of fairness in how praise or criticism is delivered, and how training, salaries, promotions, and other opportunities are provided.

• Make sure the policies for providing training, promotions, salaries and other rewards are fair and are clear to all staff.
• Avoid rewards that make some staff ‘winners’ and others ‘losers’– look for ways to reward and appreciate all of your staff.

What am I supposed to be doing in my job?

Each staff member needs a clear description of tasks and responsibilities, and appropriate tools to complete the tasks.

• Make sure each of your staff has access to their job description.
• Make sure you spend time explaining what you want your staff to do. Identify their high- and low-priority tasks. Before ending the conversation, ask “Is that clear?” “Do you have any questions?” Make yourself available if your staff have questions or concerns.
• Help your staff think through what tools, equipment or guidance s/he will need to accomplish the task. Do your best to meet these needs.

How well am I doing?

Every employee needs regular feedback on his/her performance, including both praise and constructive recommendations on how to improve.

• Give praise when it is due! Praise your staff often and sincerely. Positive reinforcement is a far more effective motivation than fear or criticism.
• Recognize staff efforts and show gratitude. Lack of recognition for hard work or a job well done can be discouraging and cause resentment among staff.
• Do not give criticism; give advice. When you need to give negative feedback, be respectful and do not dwell on the past. Remember that staff may take criticism personally and become upset or confused. Discuss with the staff member why what s/he did was not the best method, and explain clearly what you want them to do differently in the future.

Who cares?

Each staff member needs to know that his/her work is appreciated and why it matters. Share with your staff at all levels (including auxiliary staff) how their work contributes to the team and to the health of patients. One example is to inform staff of how many patients their work helps the health centre to serve, or how many children are enrolled in treatment. Remind your staff of how their work helps reach these individuals when workloads and stress are high.