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
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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