Return on Investments in Technical Assistance for TB Capacity Building?Factors Influencing Kenyan Health Workers' Performance of TB Skills

The dearth of trained personnel to implement TB/HIV services led to substantial investment in human resources and technical assistance in Kenya. Between 1999 and 2006 the staff of the TB program almost doubled. Increases in quantity of TB services occurred, but the impact on quality was unclear. Analysis of nationally representative data from the 2004 Kenya Service Provisions Assessment (KSPA) of 1,332 TB and/or HIV service providers within 440 public and private health facilities was conducted to compare performance of TB duties between those with and without TB and/or HIV training. Although the TB-HIV workforce was disproportionately female (56.9%), participation in training was less common among women of all cadres (OR 0.41 95%CI .22-.78). After controlling for structural and organizational factors, training in TB diagnosis was strongly associated with performance of smear microscopy (aOR 3.4 95%CI 1.6-7.3). Mid-level health workers were less likely than doctors to rely on smear microscopy for diagnosis (aOR 0.4 95%CI 0.2-0.6). Training was associated with direct observation of treatment (D.O.T) (aOR 3.3 CI 1.3-8.9). Other factors positively associated with performance of D.O.T included receipt of supportive supervision (aOR 3.2 CI 2.0-5.0) and an adequate TB drug supply (aOR1.2 95%CI 1.1-1.4). Barriers included non-alignment with the national directly observed short course policy program (DOTS) (aOR.0.2 95%CI 0.1-0.7) and working where high volumes of smear microscopy were performed (aOR 0.7 95%CI 0.5-1.0). Investments in capacity building including technical assistance during the 2000-2003 period were associated with performance of smear microscopy and directly observed therapy in 2004. However health system factors also influence performance.