Human ressources for health: the ultimate bottleneck ?

1. Vienna IAS conference, July 2010 Mit Philips, MD, MPH Human ressources for health: the ultimate bottleneck ?

2. Reduce & delegate clinical tasks in HIV care • Lessons learned (Southern Africa) • Patient outcomes & safety • Enabling factors: training, clinical mentoring, quality control, incentives • Psychosocial care • Drug supply & dispensing • System change • Beyond reducing the need for health workers

3. How to deal with shortfall? Increase health workforce and its output Retain, including Treat Produce, including pre-service training or import Recruit into the care system Distribute equitably, according needs Decrease need for health worker time Human resources for health care and ART

4. Decrease need for health worker time • Clinical tasks • What tasks need clinical expertise/which not ? • What patients need clinical expertise/which not? • What stages need clinical expertise /which not? • Psycho-social support • Drug supply & dispensing • Lab tests

5. Critical moments in clinical tasks Post -initiation IRIS Stage I,II Stage III,IV HAART Follow-up Long term ART Complications VCT OI Prophylaxis Initiation

6. Task shifting in Thyolo, Malawi New patients enrolled per month (initiation ARV) in Thyolo 3 “Partial” task shifting to medical assistants 1 • « Universalaccess» (district 600.000 inhab) • Without it much slower roll out • Without it need to absorb extra nurses; large proportion of annual graduation • Without it saturation ART clinic • Without it decentralisation to Health Centres not possible 2 Task shifting to medical assistants, nurses & PLWA’s 2 1 ART initiation In 7 health centres (MAs, nurses, HSA) 3

7. Are patient outcomes and safety the main concern ? • Thyolo district experience: • Outcomes : survival & loss to follow up • Care closer to home: adherence & continuity improved Hospital (n-2904) Retained2463 (84.9%) Alive 2384 (82.1 %) Transfer out 79 (2.7%) Health centres (n-1170) Retained999 (85.4%) Alive 994 (85 %) Transfer out 5 (0.4%) • Randomised proof:

8. Psycho-social support • Lay workers versus nurses • Lay counsellors • Lesotho, Malawi (HSA), South Africa • Difficulties: • Creation of new cadres (Mozambique) • Wage bill restrictions (civil servants) • Legally allowed to perform HTC including pricking blood, exceptions: Moz & Zim

9. Arrival of Lay Counselors Government reluctant to counselling by non-medical staff. Pilot: Adding lay counselors for ART initiation in health centres, Mozambique

10. Enabling factors • Training and clinical mentorship (on site) • Ongoing monitoring • Supportive supervision • Referral unit for problematic cases • Telephonic support • Treatment literacy

11. Challenges & tensions • Mid-level cadre (medical assistant, nurses, pharmacist assistants) • Legal protection (South Africa, Zimbabwe) • Career path • Retention and motivation • CHW ( HSA, counselors, expert patients) • Clinic based ? or community based • New level of cadre? • Source of payment? • Polyvalence versus competence • Turn-over and re-training

12. Review system beyond task shifting • Cancel tasks (superfluous)- Streamline patient circuit - Simplify, simplify, simplify • Frequency of patient- health facility contacts • Clinical • Drug pick up • Study Malawi: most reduction HRH needs by reduced visit freq • Keep patients without clinical needs out of the health facilities • Time and cost to patients: adherence down • Health workers’ time • Nocosomial infection risk

13. Drugs supply & dispensing • De-link dispensing from clinical care • Task shifting to pharmacy assistant • Out-of facility community meeting points: • Malawi: outreach clinics • South Africa: dispensing units send drugs to patients (cfr chronic disp unit) • Mozambique: community ART groups • Legal constraints prescription

14. Where are the limits ? • Nurses to initiate ARVs in children? Rwanda: <4% mortality at 12 months in a cohort of 312 children • Lay workers to manage stable patients without complications? Malawi + Lesotho • Home-based ART? Home-based ART and CTX associated with > 90% mortality reduction in rural Uganda (Lancet 03/08) • Lay workers to dispense ARVs? Malawi • Lay workers to initiate ARVs • Patients manage their drug supply and come into health facility only once every….

15. Tension: results on short term and long term measures How much progress since Mexico 2008 ?

16. Remember this?

17. Mexico IAS Conference 2008MSF Satellite meeting: « Mind the gaps » Healthworker crisis Task shifting helps… … but more qualified health workers needed Need for Retention => improve working conditions & salary

18. Recent HRH measures • Import health staff • E.g. Malawi, Lesotho • ARV care for staff • Re-integrate retired nurses • E.g.Mozambique, Malawi, Tanzania, S.A • Re-integrate diaspora • E.g.Lesotho, Malawi • Increase salaries through GF & other funding • E.g. Malawi, Lesotho, • Reinforce pre-service training • E.g.Lesotho, Malawi, Mozambique

19. Malawi Emergency Plan (EHRRP)6 years, US$ 270 M • Expanding domestic training capacitiestutors and infrastructure • Recruitment and retentionrecruitment galas, 52% top-ups of salaries, bonding, rural hardship incentives, staff housing • Stop-gap measures import doctors and nurse tutors (VSO and UNV) • TAs for planning and management capacity/skills development MoH and financial support for regulatory bodies • Improved monitoring & evaluation HR capacity (linked to SWAp M&E framework) • Funded by GFATM & DFID: Sustained funding?

20. Malawi EHHRP: results • Information on measures difficulty to reach district • Challenges to measurement • Availability >> where? • Yesterday, we heard from Frank Chibwandira, Malawi: Increase number health workers available • Lab and medical assistants to +/- 200% • MD, Clinical Officer to > 200% • Nurses to 140% • HAS (lay workers): +10.000 • ?? Who’ll pay to assure continuity

21. Not much change in expanding HW force- Same bottlenecks, with a few exceptions: barriers to recruit additional health staff as civil servants as non-civil servants barriers to recruit lay workers Salaries frozen at too low levels to retain, no budget for new posts, No new cadres No dissemination of exceptions' successes cc wage bill Legal and other barriers in allowing task shifting Delivery models insufficient change: systems resistant to change eg. supply & dispensing HRH: Still the major bottleneck?

22. Donors backtracking on recurrent costs Back to nurses without drugs? Additional nurses trained- but no money to recruit them? Funding for complementary workforce (NGOs, lay counsellors, supervisors of lower cadres) to be reduced? Increased need for clinic-time and clinician-time: Task shifting impossible due to rationing as patients will be more ill; decentralisation blocked Cheaper treatment options more secondary effects Funding uncertainty knock on effect on supply & adherence >> workload increase (patient frequent return & tracing defaulters) Worse ahead?

23. THANK YOU HSS