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

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 perspectives

Mozambique, number of nurses in public health services: perspectives with increased production over

next years

0

10.000

20.000

30.000

40.000

50.000

60.000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

net increase at 2170/year through training (actual situation)

net increase at 2670/year through training

net increase at 4170/year through training

WHO standard

75% of WHO standard

50 % of WHO standard

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/ PLWA’s) Community: “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 & 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

0

1000

2000

3000

4000

5000

6000

2003 2004 2005 2006

HIV testing

“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)

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2004 2005 2006 2006

Consultations

Partial task shifting to medical assistants

Task shifting to medical assistants, nurses & PLWA’s

Three health centres ++

Thyolo, Malawi: New ART- inclusions per month

0

50

100

150

200

250

300

350

400

2004 2005 2006 2006

ART Inclusions

Three health centres ++

“Partial” task shifting to medical assistants

Task shifting to medical assistants, nurses & PLWA’s

Task shifting increased ART inclusion capacity by 4 times

ART & community support

Period Jan 2003-Dec 2004 Total placed on ART 1634

Community care Community care

YES NOPlaced on ART (n-1634) 895 739

Alive & on ART 856 (96%) 560 (76%) P<0.001

Died 31 (3.5%) 115 (15.5%) P<0.001

Loss to follow up 1 (0.1%) 39 (5.2%) P<0.001

Stopped 7 (0.8%) 25 (3.3%) P<0.001

Relative Risk:

1,26[1,21-1,32]

0,22 [0,15-0,33]

0.02

[0 - 0.12]

0.23

[0.08 - 0.54]

Others

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

Lesotho:–Nurse based but shortage of nurses–PLWAs within HC and in community –Tb: difficult; TB-HIV trainer’s booklet–Cost analysis

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