Table 4 Perceptions of health system barriers to antenatal testing

Leadership and governance

Some level of policy awareness.

Limited accountability for process indicators.

Regarded as midwife-led service but no descriptions of supportive supervision of midwives by non-national participants.

National policy on universal testing not widely disseminated - poor understanding at village level.

Testing for HIV and syphilis not seen as a priority intervention with no reported inclusion in district antenatal strategy.

No indicators set; no reported follow-up or feedback on available data.

Health care financing

Sahli method chosen* as cheaper but some concerns raised about quality.

Insufficient funding for free testing seen as limiting.

Multiple small-scale funding sources, often from donors for pilot programmes.

Rapid diagnostic tests seen as expensive.

Cost effectiveness not discussed by participants.

Health workforce

Many report midwives have limited practical experience with Sahli method.

Midwives report feeling too busy to conduct testing or complete 10 T**.

Midwives and kaders aware of risk of vertical transmission but little knowledge on effectiveness of prevention.

Midwives lack training on rapid diagnostic testing for HIV and syphilis and describe being ‘afraid’ to do counselling.

Laboratory staff aware of algorithms but focused on high risk patients due to limited resources, and perceive testing as their role, concerned that quality cannot be maintained if task-shifted outside laboratory.

All levels perceive a need for counselling training as a system barrier.

Shortages of laboratory personnel and counsellors described, but only national informants discussed future possibility of task-shifting to midwives.

Medical products and technologies

Sahli accuracy seen as acceptable by all if midwives skilled.

Managers concerned about other rapid haemoglobin tests, some of which were favoured by midwives as easier.

Supplies of Sahli kit unreliable.

Reported reliance on laboratory method (RPR for syphilis; lab ELISAs for HIV) and quality assurance systems.

Little awareness of syphilis RDT at sub-national levels.

Key informants report delays in procurement of lab-based tests due to communication between different administrative levels and departments.

Information and research

Large amount of missing data on haemoglobin testing in ANC records not recognised as a problem.

Difficulties reported with integration of HIV testing into ANC data – no data fields, no reporting systems, no tracking.

Difficulties reported with integration of syphilis testing with ANC data – no data fields, no reporting systems, no tracking.

Service Delivery

Low coverage seen as suboptimal but feasible to increase within current system.

Limited community demand for service delivery.

Reliance on referral to Puskesmas on clinical suspicion but community participants describe low uptake due to cost, time and fear.

Testing all done at Puskesmas or district level.

Recognition there is very little HIV or syphilis testing happening.

National informants aware of integrated ANC testing pilot sites.

No demand for testing described with perception of low prevalence.

Stigma a significant barrier to testing amongst providers and community.

Referral only on clinical suspicion – not opt out or routine testing delivery model.

Relies on referral to Puskesmas and community participants describe low uptake due to cost, time and fear.