Task shifting: field experience and current thinking within MSF

Task shifting: field experience and current thinking within MSF

Task shifting & HRH Crisis: field experience and current thinking within MSF Mit Philips, Mdecins Sans Frontires, Brussels. WHO satelite conference, Kigali June 2007 MSF & HRH crisis Not new Post conflict Weak public health services ART & AIDS care Two pronged approach Reduce HRH-intensive workload Retention & reduce turnover

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 Standardisation Classification patients according clinical needs Streamlining

Two variations with different implications: Within profesional staff (medical/ within health system) Towards lay workers Task shifting necessary HRH gap enormous National averages underestimate problem Turn-over high & less experienced staff AIDS care reinforcement disfavouring PHC 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 Perspectives for solutions: ? Kayalitsha, South Africa: initiation bottleneck Lesotho: estimated need of nurses for ART over next years Mozambique, number of nurses in public health services: perspectives with increased production over Mozambique perspectives next years 60.000

50.000 40.000 WHO standard 30.000 20.000 75% of WHO standard 10.000 50 % of WHO standard 0 2006 2007 2008 2009

2010 2011 2012 2013 2014 2015 net increase at 2170/year through training (actual situation) net increase at 2670/year through training net increase at 4170/year through training 2016 2017

Task shifting necessary, but. Not always easily accepted Legislation, corporate institutions, insecurity Concerns of quality Need for close supervision Specialised/polyvalent (integration) 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 Feasibility:

yes But reversibility (Lusikisiki) Results Overcome bottlenecks Outcomes at patient level Lusikisiki, South Africa: nurse based ART care in health centres Lusikisiki reversed nurse-based Malawi, Thyolo district

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/ PLWAs) Community: Group/individual counselling close to Group/individual counselling close to homes (PLWA/Expert patients/Community nurses) Task shifting within clinics and beyond Clinics: from One track doctor centred to multiple flow tracks Screening & track allocation - Nurse.

Slow track - Medical assistant Complicated opportunistic infections (OI) Side effects/referred patients Medium track - Nurse Less severe OI (eg candida, diarrhoea) ART initiation /ART follow up (< 1month) Fast track - PLWA counsellor Stable patients & drug refills Doctor/Clinical officer Supervision and support Community network: Volunteers & PLWAs

Treatment : diarrhoea, fever, oral thrush. Adherence counselling (Cotrimoxazole, TB, ART) Support to family care givers at home Referral : drug reactions and Group/individual counselling close to 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 PLWAs 6000 5000 4000 3000 HIV testing

2000 1000 0 2003 2004 2005 2006 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 & PLWAs 4500 Three health centres ++ 4000 3500 3000 2500 Consultations 2000 1500 1000 500 0 2004 2005

2006 2006 Thyolo, Malawi: New ART- inclusions per month Partial task shifting to medical assistants Task shifting to medical assistants, nurses & PLWAs 400 Three health centres ++ 350 300 250 200

ART Inclusions 150 100 50 0 2004 2005 2006 2006 Task shifting increased ART inclusion capacity by 4 times ART & community support Period Jan 2003-Dec 2004 Total placed on ART 1634

Placed on ART (n-1634) Alive & on ART P<0.001 Died P<0.001 Loss to follow up P<0.001 Stopped P<0.001

Community care YES 895 856 (96%) 31 (3.5%) 1 (0.1%) Community care NO 739 Relative Risk: 560 (76%) 1,26 [1,21-1,32]

115 (15.5%) 0,22 [0,15-0,33] 39 (5.2%) 0.02 [0 - 0.12] 7 (0.8%) 25 (3.3%) 0.23 [0.08 - 0.54] Others Lesotho:

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

Task shifting not a panacea 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 Documentation/ analysis outcomes/outputs (programmatic/patients) safety Lay workers: Short term- long term policy? Thank you

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