Task shifting & HRH Crisis : field experience and current thinking within MSF

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

2. 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

3. 4 country report: **Retention central** Question limitations in policy, remuneration & resources allocation

4. 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

5. 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: ?

6. Kayalitsha, South Africa: initiation bottleneck

7. Lesotho: estimated need of nurses for ART over next years

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

9. 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?

10. Some positive results • Feasibility: yes • But… reversibility (Lusikisiki) • Results • Overcome bottlenecks • Outcomes at patient level

11. Lusikisiki, South Africa: nurse based ART care in health centres

12. Lusikisiki reversed nurse-based

13. 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)

14. 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

15. 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

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

17. 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 ++

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

19. ART & community support Period Jan 2003-Dec 2004 • Total placed on ART 1634 Community care Community care YESNO Placed 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]

20. Others • Lesotho: • Nurse based but shortage of nurses • PLWAs within HC and in community • Tb: difficult; TB-HIV trainer’s 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

21. 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?

22. Thank you