WHO / OGAC In-country: MoH & WHO Academic Institutions:

1. WHO / OGAC In-country: MoH & WHO Academic Institutions: Institute of Tropical Medicine, Antwerp, Belgium Partners in Health / Harvard Medical School Task Shifting“Clinical Mapping”Multi-country study

2. Approach • Desk work: • Previous experiences with « delegation of clinical tasks to non-doctors » in Primary Health Care programs (mainly 1980s) • Conceptualisation of task shifting • Tools for field visits • Field visits: to document experiences with innovative provider cadres in HIV care: Malawi, Uganda, Ethiopia, Haiti & Rwanda

3. Results from desk work • Framework • Types of task shifting • Evaluations done • Conditions for successful task shifting

7. 4 main types of task shifting • Type I: from doctors to non-physician clinicians (clinical officers, medical assistants, physician-assistants, nurse-practitioners, …) • Type II: from clinicians to nurses • Type III: … to nursing aids, lay providers (including counsellors), community health workers • Type IV: self-management by PLHAs

8. Type III Need to further separate Type III: • Depending on prior diploma: range: university graduates – primary school • Counsellors, becoming a new professional group • Nursing tasks • Clinical tasks = Lay providers, including « expert patients »

9. Type I Type III Type II Type III Type III

11. Prior experience? • Type I: non-physician clinicians in primary health care (PHC) • Type II: = happening in many (peripheral) places • Type III: • Community health workers = lay providers • Counsellors = quite new to HIV/AIDS • Expert patients = quite new… • Type IV: self-management (diabetes &c)

12. Evaluations of task shifting • Non-physician clinicians = very positive • Community health workers (study UWC) can work « under certain conditions! » • Still less firm evidence for recent innovations e.g. • « Nurse-based ART delivery » • « Expert patients »

13. Task shifting: 4 basic conditions • Initial training • Basic diploma • Specific pre-service training • Guidelines / protocoles (simplification) • Continuing education • Supervision • Coaching • Refresher courses • Remuneration / career structure

14. Multi-country study • Main objective: documenting ‘best practices’ in task shifting for clinical HIV care • In each country: • Inventory of all types of health cadre + training • General information on HIV, health system, HRH, AIDS programme, … • Selection of ART delivery sites: ‘best practices’ (+ ‘routine practices’)

15. Field visits to ART sites Questionnaires: • For different cadre: detailed documentation of which cadre is actually performing which tasks (mainly interview, some observation) • For each facility: • info on patients, on outcomes, … • Inventory of staff + FTE for ART

16. Expected results? • Detailed insight in task shifting: • Which tasks? by whom? • Consistent? • Priorities? • Workload (FTE staff) for ART • Conditions for enabling task shifting • Outcomes? (with task shifting)

17. « Bonus » material