How Power Relations Affect the Implementation of Policy on Equity in Access to Anti-Retroviral Therapy: The Case of Rural Health Centres in Malawi

This 22-page study seeks to understand how the power relationships between health facility managers, services providers, and patients may affect the equitable access to antiretroviral treatment (ART). Conducted over a two-month period in 2007, the study focuses on four sites in Malawi - two run by the faith-based organisation Christian Health Association of Malawi (CHAM) and two government clinics. The study found that health workers exercise a great deal of power in relation to patients and that patients typically accept this as the status quo. This was especially true in under-performing clinics. Researchers argue that poor management at such clinics demoralises health workers and leads to staff inaction that contributes to, for example, drug shortages.

As a consequence of these workplace dynamics, researchers found three specific ways in which health workers exploited their power over patients that restricted equitable access to ART. The first was non-adherence to the principle of "first come, first serve" when it came to initiating patients on treatment. In two of the sites, one run by government and the other by CHAM, health workers exercised power in giving preferential treatment to some patients who were then allowed to "jump the queue". The study hints that this may be a deterrent to seeking treatment.

Secondly, the study showed that long waiting times at clinics also hindered ART provision. Researchers note that in many clinics, long waiting times may have been exacerbated by heavy health worker workloads, but they also provide evidence to the contrary. For instance, at better performing clinics, health workers, like ART coordinators, took steps to mitigate waiting times, including arriving early, or at least on-time, for work. Researchers argue that this deliberate (in some cases) refusal to serve patients in a timely manner was yet another way in which health workers' power in relation to patients negatively impacted on service provision.

Finally, poor health worker attitudes were also a deterrent to equitable ART provision and perhaps one of the most marked demonstrations of inequitable power relations between service provider and patients. According to the report, health workers at poorly performing clinics routinely humiliated and belittled patients. Patients in two health facilities said that health workers' stigma around HIV led to their refusal to give certain drugs to HIV-positive patients because they perceived these people as "already dead". Patients also felt that health workers deliberately took breaks to chat with one another instead of attending to long queues.

According to the report, lack of access to information and knowledge by most health workers will be a threat to the equitable ART scale-up agenda and policy implementation - knowledge and information are key aspects of power in organisations and could be used by a few service providers to set and control the agenda, thereby frustrating their colleagues who do not have the same knowledge and information.

The report concludes by issuing four key recommendations that researchers argue may help mitigate negative power dynamics between service providers and patients:

• Health facilities should actively discourage health workers from dolling out preferential treatment to some patients while verbally abusing or threatening others.
• Staff should be sufficiently briefed on national guidelines that emphasise equity.
• Health facility managers should ensure that all staff are equally familiar with policies to prevent manipulation and control of agendas by any staff member.
• Drug shortages should be consistently avoided as they create opportunities for health workers to exert control over who does and does not access treatment.