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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 - PowerPoint PPT Presentation
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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