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. (Continued on next page) * Correspondence: firstname.lastname@example.org Division of Global HIV and TB at the U.S. Centers for Disease Control and Prevention, Atlanta, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gross et al. BMC Health Services Research (2018) 18:406 Page 2 of 11 (Continued from previous page) 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. Keywords: Nursing, Midwifery, Regulation, HIV, Capacity building, Sub-Saharan Africa, African health professions regulatory collaborative Background Nurses and Midwives Federation. The goal of enhancing In sub-Saharan Africa, an estimated seven million people HIV service provision by safely expanding NIMART was living with HIV still need antiretroviral treatment (ART) if supported by program objectives, including to update and targets set by the United Nations Joint Program on HIV and improve regulations (e.g. scope of practice, CPD) that AIDS are to be reached [1–3]. Studies from numerous coun- impacted the extent and quality of HIV services provided tries in sub-Saharan Africa have demonstrated that nurses by nurses and midwives . Another objective was to and midwives can provide safe and effective HIV care and strengthen the leadership, collaboration, and capacity treatment [4–12]. The World Health Organization (WHO) among the national nursing organizations in participating recommends nurse initiated and managed ART (NIMART) countries . The ARC program consisted of grants to increase ART coverage . However, it is incumbent awarded to teams of nursing and midwifery leaders from upon countries relying on NIMART to ensure that health each country to focus on improving their national regula- policies authorize NIMART and national nursing and mid- tions. The country teams were supported by regular re- wifery regulatory frameworks support nurses and midwives gional meetings and technical assistance. This study who are providing advanced HIV services [14–16]. evaluated whether the ARC program approach was In the region of East, Central and Southern Africa effective in improving national nursing and midwifery regu- (ECSA), most countries have a nursing and midwifery regu- lations and in increasing the capacity of and leadership by latory council, including Mozambique as of 2016. However, the participating nursing and midwifery organizations. the extent of regulations that support safe practices and adequate education for nurses and midwives providing HIV Methods services varies widely across this region . In a few Design countries, licensure and re-licensure regulations require This study used a retrospective analysis of routinely collected proof of competency in HIV service delivery or continuing programdataaswellaspost-programsurveydatawith17 professional development (CPD) with HIV-related content countries. The protocol for the ARC impact evaluation was [18, 19]. Nursing and midwifery scopes of practice in the reviewed and approved by the Emory University institutional region do not uniformly include NIMART or other task review board and the CDC Associate Director for Science. sharing practices [17, 20]. Pre-service education does not All participants gave individual voluntary informed consent. consistently prepare nurses and midwives to deliver essential HIV services by providing HIV content in the Participants curriculum [21–23]. Lastly, policy makers and regulators ARCwas implementedin14ECSA countries forfour years: confront capacity and resource constraints to implementing Botswana, Lesotho, Kenya, Malawi, Mauritius, Mozambique, key regulatory reforms needed to strengthen nurse-led HIV Namibia, the Seychelles, South Africa, Swaziland, Tanzania, servicedelivery. Uganda, Zambia, and Zimbabwe. Three additional countries, The African Health Professions Regulatory Collaborative Ethiopia, Rwanda, and South Sudan, participated for three Program (ARC) was designed to promote the strengthening years. In each country, ARC supported a four-person country of legal and regulatory frameworks for improved HIV care team – or a Quad – comprised of a nursing or midwifery and prevention . The program was launched in 2011 by leader from the ministry of health, the national nursing and the United States President’s Emergency Plan for AIDS Re- midwifery council, the professional nursing and midwives as- lief (PEPFAR) and the U.S. Centers for Disease Control and sociation or union, and an academic institution. Prevention (CDC) with national leaders in nursing and midwifery from 14 ECSA countries. CDC funded Emory ARC program procedures University to implement ARC in collaboration with the Grants East, Central and Southern Africa Health Community’s Through ARC, the Quads undertook one-year College of Nursing (ECSACON) and the Commonwealth grant-funded projects aimed at strengthening professional Gross et al. BMC Health Services Research (2018) 18:406 Page 3 of 11 regulation and facilitating NIMART in their country . CPD Toolkit  and the ARC Legal Regulatory Matrix Eligible topics for grants included nursing and midwifery le- . The Quads shared regulatory tools (e.g. a “needs as- gislation, registration systems, professional licensure, scope sessment” for CPD) and documents (e.g. national scopes of of practice, CPD, pre-service education accreditation, or practice) with each other and took advantage of the online professional conduct and discipline. Between five and 11 discussion board to communicate about their experiences countries received a grant each year; grants were typically tackling similar regulatory challenges related to advancing 10,000 U.S. dollars and always provided directly to the NIMART . nursing and midwifery leadership teams . The process for awarding grants was competitive and has been Variables described elsewhere . In some cases, country teams Variables used in this evaluation include ARC program garnered additional financial or in-kind support for their data (grants, regional meetings, TA) and two primary out- grant project from sources such as their national govern- comes: 1) changes in national regulations and 2) improve- ment or local non-governmental organizations [29, 30]. ments in leadership and organizational capacity. 1) Program Data Regional meetings Two types of meetings were held for ARC country teams Grants: the number of grants a country team each year: regional meetings called “Learning Sessions” received and the topic (e.g. SOP, CPD, nursing were held twice a year for countries implementing a grant legislation) that year; an annual meeting or “Summative Congress” was Regional Meetings: the number of Learning Sessions attended by all ARC countries. At Learning Sessions, Quads and Summative Congresses attended by the Quad formally presented their funded projects and identified Technical Assistance: the amount and type (in- challenges and solutions they encountered during imple- country, remote, learning session if non-grantee) of mentation. They received feedback and suggestions from TA received by country teams. Three levels were de- their colleagues and technical consultations from ARC fac- veloped to quantify TA; the levels for all four years ulty and subject matter experts. All 17 country teams con- were added together for a composite TA score, vened annually for the Summative Congress. Countries that which could range from 0 to 12: had implemented a grant project that year would present ○ Level 1: remote TA only (e.g. phone or email their project to all the other Quads. International and re- consultations, document review) gional experts in regulation and NIMART presented on ○ Level 2: one in-country or in-person topics related to the countries’ grant topics. Networking consultation by an ARC TA provider, with or events were held at each meeting and helped deepen rela- without additional remote TA tionships among and across country teams and encourage ○ Level 3: two or more in-country or in-person cross-country collaboration on common regulatory issues. consultations by an ARC TA provider Technical assistance 2) National Nursing and Midwifery Regulations: In Technical assistance (TA) was provided to country teams order to assess if regulations changed over the course of implementing a grant. Most often, a member of the ARC the ARC program, each country reported on the status of faculty or a subject matter expert visited the Quad seven nursing and midwifery regulations each year. In in-country; occasionally the TA was provided remotely. In addition, country teams that received a grant would certain circumstances, Quads that did not receive a grant provide a “pre” and “post” status on the regulation ad- could still get TA on the topic they identified in their (un- dressed by their grant that year. Changes in regulations funded) grant proposal. These Quads would attend a were measured using the Regulatory Function Framework Learning Session that year to receive in-person TA from (RFF), described below. the ARC faculty and experts present, as well as benefit 3) Leadership and Organizational Capacity: Country from the speakers and country presentations in the Learn- teams were asked to report on five specific domains of ing session. This overall structure of ARC—country teams leadership, collaboration, and organizational capacity. The working collaboratively on an improvement project and domains were selected and defined relative to the initial regularly convening to assess progress—was designed to objectives of the ARC program : mimic the Institute for Healthcare Improvement’smodel for “breakthrough change” [26, 31]. 1. Teamwork: the national nursing and midwifery leaders Grants, regional meetings, and TA were reinforced by a (“the Quad”) work together effectively as a team virtual community of practiceusing theKnowledge 2. In-country Collaboration: the national nursing and Gateway platform. Through the Knowledge Gateway, ARC midwifery organizations collaborate with each other offered policy and regulation resources, such as the ARC to accomplish mutual goals Gross et al. BMC Health Services Research (2018) 18:406 Page 4 of 11 3. Intra-professional Collaboration: the national Data collection on regulations took place at the ARC nursing and midwifery organizations collaborate Summative Congresses in June 2012, June 2013, February with other in-country organizations 2015, and February 2016. 4. Regional Collaboration: the national nursing and 3) Country teams completed one survey per country to midwifery leaders network and collaborate with facilitate discussion and agreement regarding their leader- nursing and midwifery leaders from other countries ship, collaboration, and organizational capacity before and 5. Resource Mobilization: the national nursing and after their participation in the ARC initiative. The survey midwifery leaders garner resources and funding, was administered at the ARC Summative Congress in beyond that provided by ARC, to advance nursing February 2016. and midwifery regulation within their countries. Analysis Instruments We tabulated the program data on grants, regional meet- 1) Data on the major components of the ARC program (i.e. ings and TA from all four years. The two primary program grants, regional meetings, TA) were collected via routine outcomes (1) changes in regulations and (2) improve- program management by Emory University and used for ments in leadership and organizational capacity were ana- reporting to CDC and PEPFAR. lyzed according to their relationship to the program data. 2) Changes in regulatory functions were measured by We compared the regulation data collected from the RFF the Regulatory Function Framework (RFF). The creation in June 2012 (Year 1) to the data collected in February of the RFF was led by the CDC to measure the impact of 2016 (Year 4) for all 17 countries; improvement was de- the ARC program on national regulations. The RFF fined as movement of at least one stage on the RFF. Rele- comprises seven regulatory functions, including nursing vant country-level characteristics, including the number of and midwifery legislation, registration systems, licensure years in ARC, English as a national language, a country’s process, SOP, CPD, pre-service education accreditation, regional location, and receipt of PEPFAR support, were in- and professional conduct and discipline . The RFF al- cluded in the analysis. Analysis for both outcomes in- lows for assessment of the regulatory functions in terms cluded checking the ordinal and categorical data for of five distinct stages: “ad hoc” (stage 1), “documented” completeness and reviewing for accuracy. Non-parametric (stage 2), “routine” (stage 3), “improved” (stage 4), and statistical tests (i.e. Mann-Whitney U tests, Wilcoxon rank “optimized” (stage 5) . The stages are sequential and sum paired tests, and Kendall’s tau correlations), as well as each stage is characterized by elements of regulation that chi-square tests were performed to test for significant must be in place; advancing a stage represents a meaning- changes on the RFF from year 1 to year 4 and to assess as- ful step towards a more optimal regulation . A de- sociations between ARC program data, the two primary scription of the stages for each regulatory function and outcomes, and relevant country-level characteristics. SPSS their respective elements are presented in Additional file 1. v.23® was used for statistical analysis with 5% level of The development of the RFF and results of use by the significance for all hypothesis tests. ARC program has been published previously [27, 34, 36]. 3) Changes in leadership and organization capacity were Results assessed by a survey instrument designed by the ARC fac- ARC program: Grants, meetings, technical assistance ulty. The survey included qualitative and quantitative Likert Grants scale questions, which asked country teams to rate them- Between 2012 and 2016, ARC awarded a total of 33 com- selves in the five domains of leadership, collaboration, and petitive grants addressing specific regulatory functions to organizational capacity both before and after their participa- improve HIV care provided by nurses and midwives; all 17 tion in the ARC program. A detailed description of the sur- countries received at least one grant (Table 1). The majority vey’s qualitative results has been published elsewhere . of grants (61%) supported the establishment and strength- ening of national CPD programs and linking licensure Data collection renewal to specific CPD requirements, such as content on 1) Program data were collected annually at the Summa- HIV and AIDS care. Six grants (18%) supported nursing tive Congress and throughout year as TA occurred. and midwifery SOP projects, followed by three grants (9%) 2) At the Summative Congress, Quads discussed the to strengthen the licensure process. Two grants (6%) stages of each of the seven regulatory functions and provided focused on establishing or revising nursing and midwifery the information to ARC faculty. These data were collected as legislation. Lastly, one grant (3%) focused on pre-service an annual “point in time” assessment of in all seven regula- nursing and midwifery program accreditation and one (3%) tory functions on the RFF for each country. For countries on enhancing the nursing and midwifery registration that received a grant that year, “before grant” and “after system. Four countries implemented grants addressing two grant” data were collected about the targeted regulation. regulatory topics. Gross et al. BMC Health Services Research (2018) 18:406 Page 5 of 11 Table 1 Table of ARC grantees by Country, number of Grants, regulatory function and advancement Country # ARC grants Primary regulatory # Stages Highest RFF Resulting regulatory product Impact on received function (Secondary) advanced stage reached HIV Care on RFF Botswana 2 CPD 1 Stage 2 CPD Framework requiring HIV content; 5 HIV-related CPD points Scope of Practice including HIV tasks; are required; Task sharing 1 SOP 2 Stage 5 CPD requirement for re-licensure included; CPD needed to re-license Ethiopia 1 CPD 1 Stage 2 CPD Manual, including HIV content Quality improvement Kenya 1 Registration 0 Stage 4 Establishment of decentralized Convenient re-licensing; council offices; HIV CPD to recertify 1 CPD 0 Stage 3 Pediatric HIV CPD module; Lesotho 3 CPD 3 Stage 5 Trainings to increase CPD compliance; Increased CPD compliance; (Licensure) CPD requirement for re-licensure and 3 of 12 CPD points are CPD provider accreditation application; required in HIV-related CPD Framework and Logbook CPD; Instituted CPD for nurses Malawi 1 CPD 1 Stage 4 Trainings to implement CPD mandate Increased CPD compliance Mauritius 1 Legislation 1 Stage 2 Regulation of Profile for Educators Quality nursing education Mozambique 2 Licensure 0 Stage 1 Objective Structured Clinical Exam (OSCE) Assessment of PMTCT (Accreditation) assessment for new nursing graduates; competencies for new Law establishing Nursing Council nurses; 0 (TA only) Legislation 2 Stage 3 Professional regulation Namibia 1 CPD 1 Stage 3 Survey assessed CPD compliance factors Data to drive compliance Rwanda 1 SOP 1 Stage 3 Scope of Practice, including HIV tasks; Task sharing included; CPD module on HIV services HIV CPD available 1 CPD 1 Stage 2 Seychelles 1 Legislation 4 Stage 5 Proposed amendments to Nursing Act; Clear HIV practice scope; Scope of Practice for HIV Generalists CPD available to nurses; 1 SOP 0 Stage 2 and Specialists; Improve education/ CPD Framework including HIV content practice 1 CPD 1 Stage 2 South Africa 1 CPD 1 Stage 2 HIV Specialization for nurses; Incentive for task sharing; (Accreditation) CPD accreditation for nurse led ART Quality ART task sharing 1 Accreditation 0 Stage 3 South Sudan 1 SOP 0 Stage 1 Scope of Practice, including HIV tasks Clear HIV practice scope Swaziland 2 CPD 2 Stage 4 CPD Framework, including HIV content; HIV CPD required to Entry to practice license exam includes relicense; HIV 1 Licensure 2 Stage 4 HIV competencies required Tanzania 2 CPD 1 Stage 2 CPD Framework, including HIV content; HIV CPD required to Task Sharing Policy, includes HIV services relicense; Increased HIV task sharing Uganda 2 SOP 2 Stage 3 Scope of Practice for Nurses and Nurses are authorized to Midwives, Uganda Nursing initiate patients on ART Council, 2015 Zambia 2 CPD 1 Stage 2 CPD requirement for licensure renewal; HIV CPD required to (Licensure) Nurse led ART accreditation guidelines relicense; Quality ART task sharing Zimbabwe 2 CPD 2 Stage 5 NIMART Mentorship Training Program; Quality ART task sharing; CPD requirement for licensure renewal CPD required to relicense Regional meetings Rwanda, South Africa, Tanzania, Uganda, and Zimbabwe). ARC convened 13 collaborative regional meetings (i.e. Learn- Five countries (29.4%) attended 5–6 collaborative regional ing Sessions and Summative Congresses) in nine African lo- meetings (Namibia, South Sudan, Ethiopia, Malawi, and cations over the course of the initiative (Additional file 2). Mauritius). There was a relationship between the number of Five countries (29.4%) attended 9–10 collaborative regional grants received and the number of collaborative regional meetings over the four years (Botswana, Lesotho, Seychelles, meetings attended (Kendall’stau=0.91, p < 0.01). The num- Swaziland, and Zambia). Seven countries (51.2%) attended ber of learning sessions was also directly correlated with the 7–8 collaborative regional meetings (Kenya, Mozambique, number of years a country participated in ARC (Kendall’s Gross et al. BMC Health Services Research (2018) 18:406 Page 6 of 11 tau = 0.53, p < 0.02); however, the number of years in ARC National Nursing and midwifery regulations was not significantly associated with the number of grants a Over the course of the ARC initiative (2012–2016), coun- country received (Kendall’sTau=0.37, p =0.12). tries reported advancements on the RFF across all seven regulations (Fig. 2). There were significant advancements Technical assistance in five regulations including CPD (p < 0.01), professional The number of years of receiving TA and the composite TA discipline (p <0.01), SOP (p =0.01), licensure (p <0.02), scores were calculated separately for each country (Fig. 1). and registration (p = 0.03); advancements for accreditation The years of TA ranged from zero to 4-years. One country (p < 0.06) and legislation (p = 0.32) were not statistically (6%), Malawi, did not receive any TA. One country (6%), significant. In 2012, CPD was the least-developed regula- Mozambique, received the maximum of four years of TA to tion in the region: 11 of the 17 countries (65%) were in advance national nursing and midwifery legislation to estab- Stage 1, indicating unorganized or ad hoc approaches to lish a regulatory council. Fifteen countries (88%) received be- CPD; by the end of ARC, only three countries (18%) were tween one and three years of TA; the most common number in Stage 1. The SOP function was also under-developed at of years of TA received was one (eight countries, 47%), the start of ARC: ten countries (59%) were in the earliest followed by three (four countries, 24%). The composite TA two stages of development; by the end of ARC, only five scores ranged from zero (Malawi) to eight (Botswana). Seven countries (29%) were in these stages and seven (41%) countries (41%) had composite TA scores of five and above; countries had reached to the most advanced stage. while, nine countries (53%) had a composite TA scores of Among countries reporting pre- and post- changes in two or below. There was a clustering of nine countries with the regulation topic addressed by their one-year grant, 14 low duration (one year or less) of TA and low composite TA countries (representing 20 of 33 grants) progressed at least scores (two and below); this clustering was not mirrored in one stage on the RFF per project grant (Table 1). We also countries with high TA scores: seven countries (41%) with examined the singular effect of receiving a grant upon composite TA scores of five and above ranged in duration of regulatory function improvement by comparing advance- TA between two and four years. There was a correlation be- ment on the RFF by countries that received a grant in that tween the number of grants received and the number of function and those that did not. The 13 countries that re- years of TA received (Kendall’s tau = 0.49, p < 0.03), as well as ceived CPD grants (61% of grants) improved their CPD the composite TA score (Kendall’s tau = 0.56, p < 0.01). stage significantly more from year 1 to year 4 (median Fig. 1 Range of Technical Assistance Received by Duration (# Years) and Dose (Composite TA Score) Gross et al. BMC Health Services Research (2018) 18:406 Page 7 of 11 Fig. 2 Countries’ Regulatory Function Maturity at Baseline (2012) and Endline (2016) of ARC (n = 17 countries) improvement of 1 stage) than those without a CPD grant An analysis of the program data outputs with the (median improvement 0 stages). The five countries that nursing and midwifery leadership and capacity domains received SOP grants also improved by a median of 1 stage; identified five significant relationships. In the domain of however, the median improvement in this function by in-country collaboration between nursing organizations, countries that did not receive a grant (0.5 stages) was not the number of grants (Kendall’s tau = 0.56, p = 0.02), dur- statistically different. We noted no statistical difference be- ation of TA (Kendall’s tau =0.50, p = 0.03), and number tween grantees’ and non-grantees’ median improvements of learning sessions attended (Kendall’s tau = 0.46, p = for licensure, accreditation, and legislation functions. Only 0.04) were all significantly associated with improve- one country received a registration function grant, and ments. The duration of TA was significantly associated none received a disciplinary function grant. with improvements in intra-professional collaboration (Kendall’s tau = 0.44, p = 0.05) and the ability to mobilize resources (Kendall’s tau = 0.60, p = 0.01). Leadership and organizational capacity We found significant increases in the country teams’ Discussion ranking of leadership and organizational capacity before We evaluated the four-year 17-country ARC initiative by and after the four-year ARC initiative for all five capacity assessing the major program components (grants, regional domains (p < 0.01) (Fig. 3). While the changes in all five meetings, and TA) and analyzing their relationship to two capacity and leadership domains were statistically signifi- outcome variables: improvements in national regulations cant, three had the largest effect size, including: 1) team- and increases in nursing and midwifery leadership and work among a country’s nursing and midwifery leaders, 2) organizational capacity. We found the ARC program to be in-country collaboration among nursing/midwifery organi- effective in improving national regulations: most grantees zations, and 3) regional collaboration with nursing and (20 of 33) progressed at least one stage on the RFF regard- midwifery leaders from other countries. Less than 15% of less of regulatory function. While not all progress on the countries scored these domains as strong or very strong be- RFF was statistically significant, a gain of any stage on an fore ARC, compared to more than 85% following the initia- instrument such as the RFF indicates meaningful improve- tive. For the remaining domains, less than 13% of countries ment . The greatest improvements for the region were scored intra-professional collaboration as strong or very in the regulations of CPD and SOPs. Thirteen countries strong before ARC, compared to 73% after the initiative; re- that received CPD grants demonstrated statistically source mobilization improved from 7% of countries scoring significant improvements in this regulatory function. Three strong or very strong before ARC to 54% after the initiative. countries made statistically significant advancements in de- A more detailed and qualitative description of changes in veloping or updating the nursing and midwifery SOP. the nursing and midwifery capacity domains is reported Because ARC focused “upstream” on regulations, in- elsewhere . stead of directly at point of service provision, the Gross et al. BMC Health Services Research (2018) 18:406 Page 8 of 11 Fig. 3 ARC’s Impact on National Nursing Leaders’ Teamwork, Collaboration and Resource Mobilization (n = number of countries) improvements reflect crucial and sustainable changes in documented as a key obstacle to strengthening workforce national health policies. For example, seven countries regulations [24, 38]. Furthermore, the duration of TA (Botswana, Ethiopia, Rwanda, Seychelles, South Africa, significantly improved nursing and midwifery organi- Tanzania, and Zambia) established national CPD pro- zations’ ability to mobilize additional external re- grams and made CPD mandatory for licensure renewal. sources to advance national regulatory priorities. The Four additional countries (Malawi, Swaziland, Lesotho, ability to secure financing is a critical skill to allow and Zimbabwe) reported that content on HIV service de- regulatory bodies to move towards self-sufficiency in livery must be included in CPD for nurses and midwives. resource-constrained environments . The improvements in SOPs in three countries (Botswana, The improvements in regulation and organizational Rwanda, and Uganda) resulted in new or expanded SOPs capacity have moved ARC countries closer to global that now reflect national guidelines for HIV task sharing targets for HIV service delivery, health systems strength- and NIMART. The popularity of the CPD and SOP func- ening, and health workforce development. The 2016 tions (26 of 33 grants) indicated clear priorities in profes- WHO ART guidelines recommend using task sharing sional regulation among nursing and midwifery leaders in and updated regulations that facilitate NIMART to treat the ECSA region. The ARC program not only contributed all people living with HIV . Additional guidance to the substantial advancement of these regulations but from WHO recommends using national laws and health also fostered similar approaches by countries to improving professional regulations to strenghten health systems the regulations. The result is greater harmonization of reg- and increase population health coverage . Countries ulations in the ECSA region, which helps address increas- in ARC are closer to achieving several global milestones ing mobility of healthcare workers [38, 39]. outlined in WHO’s Global strategy for human resources The ARC initiative was also effective in developing the for health: Workforce 2030 . The Global Strategy leadership and organizational capacity of nursing and midwif- underscores the need for strong regulatory mechanisms ery leaders in the ECSA region. While there were improve- and specifically mentions strengthening the capacity of ments in self-assessment of leadership and organizational professional regulatory councils and enhancing in-country capacity across all five domains from Year 1 to Year 4, the collaboration among councils, professional associations, largest effect size was seen in the domains of teamwork, and governments . Additional principles of the Global in-country collaboration, and regional collaboration. These Strategy include ensuring the competency and facilitating three are the most directly related domains to stated ARC the mobility of health workers. Lastly, the WHO’s Global objectives  and address some of the biggest deficits in the Strategic Directions for Nursing and Midwifery 2016–2020 region. All three ARC program components – competitive urges countries to maximize the capacities of nurses and grants, regional meetings, and TA – significantly improved midwives through intra- and interprofessional collabora- in-country collaboration. The lack of collaboration between tive partnerships and continuing professional develop- national nursing and midwifery organizations has been ment . Gross et al. BMC Health Services Research (2018) 18:406 Page 9 of 11 Limitations networking), countries could advance regulatory functions This evaluation has several limitations. The RFF was devel- without necessarily needing a grant. Countries without oped for use within the ARC initiative to assess advance- grants also made progress in advancing regulations (e.g. ments in regulatory functions. While it went through a disciplinary powers function) to facilitate safer HIV and validation process by countries within ARC, it was not ex- health service delivery. Mozambique received four years of ternally validated by a wider audience. The RFF was not TA to advance national nursing and midwifery legislation, sensitive enough to document certain sub-national or HIV improving two stages withoutagrantand ending in the specific advancements in regulations. For example, the passage of a national law to establish a nursing council. Mozambique Quad developed an objective structured clin- ical examination, or OSCE, as part of the competency as- Conclusion sessment for entry to practice. While this new examination The ARC program was effective in improving national will help ensure fitness to practice in Mozambique and is regulations and increasing leadership and organizational an impressive accomplishment, the licensing regulation on capacity in the ECSA region. The achievements in devel- the RFF did not capture this development. Similarly, South oping health professional regulation and regulatory cap- Africa developed accreditation standards for a specialty cer- acity can help countries in the ECSA region meet tification for NIMART and tuberculosis care linked to in- national targets for HIV service delivery, universal health creased remuneration. While not captured by the RFF, the coverage, and a stronger health workforce. ARC provides development of a NIMART/NIMTB specialty certification an illustrative model for sustained change that is trans- is certainly a marked achievement in South Africa, linking ferable to other regions and healthcare cadres with simi- advanced nursing practice to HIV care. Additionally, some lar regulatory challenges. countries, like Kenya, made incremental advancements that did not result in stage advancements. Endnotes Although the RFF and nurse capacity tools were ad- The ARC Knowledge Gateway was created using the ministered as group surveys to facilitate discussion and WHO’s free, web-based platform, allowing members to improve reporting accuracy, they are both subject to so- share a shared discussion board, virtual library and com- cial desirability bias. The nursing capacity tool is subject munity calendar. to recall bias. Additionally, not all regulatory advance- ments by countries in ARC can be attributed to the Additional files ARC initiative. During the project, other global health and PEPFAR initiatives had similar objectives of enhan- Additional file 1: Regulatory Function Framework (PDF 598 kb) cing HIV service delivery by nurses and midwives and Additional file 2: Regional ARC Summative Congresses and Learning Sessions, 2011–2016 (PDF 196 kb) may have concurrently supported efforts that enhanced regulation or nursing and midwifery organizational cap- Abbreviations acity . Furthermore, other domestic inputs may have AIDS: Acquired Immunodeficiency Syndrome; ARC: African Health Professions played an important role in advancing nursing and mid- Regulatory Collaborative; ART: Antiretroviral Therapy; ASPPH: Association of Schools and Programs of Public Health; CDC: U.S. Centers for Disease Control wifery regulation within the ECSA region. The small and Prevention; CPD: Continuing Professional Development; sample size of 17 countries, as well as the small range DENOSA: Democratic Nursing Organization of South Africa; ECSA: East and measurement scale (number of years 1 to 4 and Central and Southern Africa; ECSACON: East Central and Southern Africa College of Nursing; ECSA-HC: East Central and Southern Africa Health stages 1 to 5) limited the statistical analysis. Community; HIV: Human Immunodeficiency Virus; NCSBN: National Council The structure of the intervention package accounts for of State Boards of Nursing; NIMART: Nurse Initiated and Managed some of the relationships identified in the results. For ex- Antiretroviral Therapy; NIMTB: Nurse Initiated and Managed Tuberculosis; OSCE: Objective Structured Clinical Examination; PEPFAR: President’s ample, the correlation between the number of grants re- Emergency Plan for AIDS Relief; RFF: Regulatory Function Framework; ceived and the duration and dose of TA received explains SOP: Scope of Practice; TA: Technical Assistance; TB: Tuberculosis; the clustering of nine countries with a fairly low TA dur- UNAIDS: Joint United Nations Programme on HIV/AIDS; WHO: World Health Organization ation (≤ 1 year) and dose (≤ 2 composite TA score). For these nine countries, over 50% received only one ARC Acknowledgements grant. The eight countries with higher TA durations and The authors acknowledge the leadership of nursing and midwifery country doses all received two or more grants. The correlation be- teams across east, central and southern Africa for their advancement of national nursing and midwifery workforce regulations to promote the tween the number of grants received and the number of delivery of quality health services, including HIV care. Acknowledgement is collaborative regional meetings attended is also due to the given to the CDC country office staff for the provision of technical support structure of the intervention package, since the majority of to nursing leaders, as they implemented their ARC projects to expand NIMART nationally, including Diriisa Musisi and Mary Naluguza from CDC participants invited to learning sessions were grantees. Uganda and Rehmeth Fakrodeen from CDC South Africa. Michelle Dynes is Given certain elements of ARC (i.e. TA, collaborative learn- recognized for her role in developing the nursing and midwifery capacity ing sessions, exchange of regulatory tools, regional evaluation tool. Gross et al. BMC Health Services Research (2018) 18:406 Page 10 of 11 Funding cascade: findings from health facility surveys in six sub-Saharan countries. J This research was supported by the President’s Emergency Plan for AIDS Int AIDS Soc. 2017;20:1–14. https://doi.org/10.7448/IAS.7420.7441.21188. Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention 6. Brennan AT, Long L, Maskew M, Sanne I, Jaffray I, et al. (2011) Outcomes of (CDC) under the terms of a cooperative agreement with the Association of stable HIV-positive patients down-referred from a doctor-managed Schools and Programs of Public Health (ASPPH) grant number antiretroviral therapy clinic to a nurse-managed primary health clinic for 1U36OE000002. The findings and conclusions of this article are those of the monitoring and treatment. AIDS 25: 2027–2036. doi: 2010.1097/QAD. authors and do not necessarily represent the official position of the CDC. 2020b2013e32834b36480. This evaluation was supported by the National Council of State Boards of 7. Martinez-Gonzalez NA, Tandjung R, Djalali S, Rosemann T. The impact of Nursing (NCSBN) through funding provided to the Emory University Nell physician-nurse task shifting in primary care on the course of disease: a Hodgson Woodruff School of Nursing. systematic review. Hum Resour Health. 2015;13:55. https://doi.org/10.1186/ s12960-12015-10049-12968. Availability of data and materials 8. Kredo T, Adeniyi FB, Bateganya M, Pienaar ED (2014) Task shifting from The datasets used and/or analyzed during the current study are available doctors to non-doctors for initiation and maintenance of antiretroviral from the corresponding author on reasonable request. therapy. Cochrane database Syst rev: CD007331. doi: 007310.001002/ 14651858.CD14007331.pub14651853. Authors’ contributions 9. Penazzato M, Davies MA, Apollo T, Negussie E, Ford N (2014) Task shifting JG, CM and PR conceived the study. JG, CM, KH and PR drafted and revised the for the delivery of pediatric antiretroviral treatment: a systematic review. J article. MK, KH, AK and AW facilitated data collection. JG and MH analyzed the Acquir Immune Defic Syndr 65: 414–422. doi: 410.1097/QAI. data. AV and JI analyzed the regulatory products’ impact on HIV care. All authors participated in critical revisions and final manuscript approval. 10. Iwu EN, Holzemer WL (2014) Task shifting of HIV management from doctors to nurses in Africa: clinical outcomes and evidence on nurse self-efficacy Ethics approval and consent to participate and job satisfaction. AIDS Care 26: 42–52. doi: 10.1080/09540121.09542013. The protocol for this study was reviewed and approved by the Emory University 09793278. Epub 09542013 May 09540123. institutional review board and the CDC Associate Director for Science. All 11. Mdege ND, Chindove S, Ali S (2013) The effectiveness and cost implications participants gave individual voluntary informed consent, and the authors of task-shifting in the delivery of antiretroviral therapy to HIV-infected obtained all necessary administrative permissions to access and use the data. patients: a systematic review. Health Policy Plan 28: 223–236. doi: 210.1093/ heapol/czs1058. Epub 2012 Jun 1026. Competing interests 12. Nkhata MJ, Muzambi M, Ford D, Chan AK, Abongomera G, et al. Shifting All co-authors, except MH, participated in the implementation of the ARC ini- human resources for health in the context of ART provision: qualitative and tiative through their organizational affiliations. MH has no competing inter- quantitative findings from the Lablite baseline study. BMC Health Serv Res. ests to declare. 2016;16:660. 13. World Health Organization. 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