Transcript Task shifting: field experience and current thinking within MSF

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
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Not new
– Post conflict
– Weak public health services
ART & AIDS care
 Two pronged approach
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– Reduce HRH-intensive workload
– Retention & reduce turnover
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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
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Simplification
 Standardisation
 Classification patients according clinical needs
 ‘Streamlining’
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Two variations with different implications:
– Within profesional staff (medical/ within health system)
– Towards lay workers
Task shifting necessary
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HRH gap enormous
– National averages underestimate problem
– Turn-over high & less experienced staff
– AIDS care reinforcement disfavouring PHC
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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
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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….
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Not always easily accepted
– Legislation, corporate institutions, ‘insecurity’
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Concerns of quality
– Need for close supervision
– Specialised/polyvalent (integration)
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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
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– Overcome bottlenecks
– Outcomes at patient level
Lusikisiki, South Africa:
nurse based ART care in health centres
Lusikisiki reversed nurse-based
Malawi, Thyolo district
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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”
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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
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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
“Task shifting” : Nurses to PLWA’s
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
assistants, nurses & PLWA’s
4500
Three health centres ++
4000
3500
3000
2500
Consultations
2000
1500
1000
500
0
2004
2005
2006
2006
Thyolo, Malawi: New ART- inclusions per month
“Partial” task shifting
to medical assistants
Task shifting to medical assistants, nurses & PLWA’s
400
Three health centres ++
350
300
250
200
ART Inclusions
150
100
50
0
2004
2005
2006
2006
Task shifting increased ART inclusion capacity by 4 times
ART & community support
Period Jan 2003-Dec 2004
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Total placed on ART
Placed on ART (n-1634)
1634
Community care
YES
895
Community care
NO
739
Relative
Risk:
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Alive & on ART
P<0.001
856 (96%)
560 (76%)
1,26
[1,21-1,32]
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Died
P<0.001
31 (3.5%)
115
(15.5%)
0,22
[0,15-0,33]
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Loss to follow up
P<0.001
1 (0.1%)
39
(5.2%)
0.02
Stopped
P<0.001
7 (0.8%)
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[0 - 0.12]
25 (3.3%)
0.23
[0.08 - 0.54]
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
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Burkina Faso:
– Towards patient groups and associations
– Drug supply also in community?
– Not a high prevalence context
Task shifting not a panacea
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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
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Documentation/ analysis
– outcomes/outputs (programmatic/patients)
– safety
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Lay workers: Short term- long term policy?
Thank you