Task shifting HRH Crisis field experience and current

Task shifting & HRH Crisis: field experience and current thinking within MSF Mit Philips, Médecins Sans Frontières, Brussels. WHO satelite conference, Kigali June 2007

MSF & HRH crisis n Not new – Post conflict – Weak public health services n ART & AIDS care n Two pronged approach – Reduce HRH-intensive workload – Retention & reduce turnover n Operations & policy dialogue

4 country report: **Retention central** Question limitations in policy, remuneration & resources allocation

Task shifting: one of the measures to reduce HRH-needs for ART Simplification n Standardisation n Classification patients according clinical needs n ‘Streamlining’ n n Two variations with different implications: – Within profesional staff (medical/ within health system) – Towards lay workers

Task shifting necessary n HRH gap enormous – National averages underestimate problem – Turn-over high & less experienced staff – AIDS care reinforcement disfavouring PHC n HRH gap affecting scale up AIDS care – Patient load increasing: follow-up +++ – Decentralisation: major understaffing periferal health centres & rural areas – Integration: mission impossible without HRH – Most affected: ART initiation > follow up n Perspectives for solutions: ?

Kayalitsha, South Africa: initiation bottleneck

Lesotho: estimated need of nurses for ART over next years

Mozambique perspectives WHO standard 75% of WHO standard 50 % of WHO standard

Task shifting necessary, but…. n Not always easily accepted – Legislation, corporate institutions, ‘insecurity’ n Concerns of quality – Need for close supervision – Specialised/polyvalent (integration) n Policy concerns – No excuse: still need sufficient qualified staff – Salary of extra workers? On budget? - caps? – Lay workers: in/outside health system? In/off budget?

Some positive results n Feasibility: yes n But… reversibility (Lusiki) n Results – Overcome bottlenecks – Outcomes at patient level

Lusiki, South Africa: nurse based ART care in health centres

Lusiki reversed nurse-based

Malawi, Thyolo district n n n n Vacant positions: • Nursing staff 64% • Clinical officers 53% • Doctors / Specialists 85 -100% Nurse/health facility • < 1. 5 nurses per health facility in 15/29 districts Doctors/district • 10 districts with no MOH doctor. • 4 districts have no doctor at all ART Target: 10, 000 (+-1000) On ART 5, 613 (Dec 2006) ART initiations/Month 400 Initial perspective: target by 2012; with task shifting achieved Nov 2007 Health facilities: flow tracks” (Nurses/ PLWA’s) n Community: “Group/individual counselling” close to homes (PLWA/“Expert patients”/Community nurses) n n

Task shifting within clinics and beyond Clinics: from “One track” doctor centred to “multiple flow tracks” Screening & track allocation - Nurse. n Slow track - Medical assistant • Complicated opportunistic infections (OI) • Side effects/referred patients n Medium track - Nurse • Less severe OI (eg candida, diarrhoea) • ART initiation /ART follow up (< 1 month) n Fast track - PLWA counsellor • Stable patients & drug refills Doctor/Clinical officer – Supervision and support n

Community network: Volunteers & PLWA’s – Treatment : diarrhoea, fever, oral thrush…. – Adherence counselling (Cotrimoxazole, TB, ART) – Support to family care givers at home – Referral : drug reactions and “risk signs”. – Cough screening (TB) – Social mobilisation. – Further? Community based drug supply & screening for problems in stable ART patients

Counselling & Testing: Average/Month in Thyolo, Malawi “Task shifting” : Nurses to PLWA’s Task shifting increased CT capacity by 5 times

Thyolo, Malawi: Number of consultations per month (2 main hospital sites) Partial task shifting to medical assistants Task shifting to medical assistants, nurses & PLWA’s Three health centres ++

Thyolo, Malawi: New ART- inclusions per month “Partial” task shifting to medical assistants Task shifting to medical assistants, nurses & PLWA’s Three health centres ++ Task shifting increased ART inclusion capacity by 4 times

ART & community support n Total placed on ART Placed on ART (n-1634) Period Jan 2003 -Dec 2004 1634 Community care YES 895 Community care NO 739 Relative Risk: n Alive & on ART P<0. 001 856 (96%) 560 (76%) 1, 26 [1, 21 -1, 32] n Died P<0. 001 31 (3. 5%) 115 (15. 5%) 0, 22 [0, 15 -0, 33] n Loss to follow up P<0. 001 1 (0. 1%) 39 (5. 2%) 0. 02 Stopped P<0. 001 7 (0. 8%) n [0 - 0. 12] 25 (3. 3%) 0. 23 [0. 08 - 0. 54]

Others n. Lesotho: –Nurse based but shortage of nurses –PLWAs within HC and in community –Tb: difficult; TB-HIV trainer’s booklet –Cost analysis n Mozambique: problems in policy environment – Counselling by nurses who are already overloaded – PMTCT: Initiation versus regularity – Request tests by MD or TM only: bottleneck n Burkina Faso: – Towards patient groups and associations – Drug supply also in community? – Not a high prevalence context

Task shifting not a panacea n Inventory/clarification within MSF projects – What objectives? – Where? High prevalence context only? – What degree? What tasks? Within medical staff? Lay workers? – Tools for analysis, training, method n Documentation/ analysis – outcomes/outputs (programmatic/patients) – safety n Lay workers: Short term- long term policy?

Thank you