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, 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 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
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

“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 Task shifting to medical

medical assistants assistants, nurses & PLWA’s
4500
4000 Three health centres ++

3500
3000
2500
2000 Consultations
1500
1000
500
0
2004 2005 2006 2006
Thyolo, Malawi: New ART- inclusions per month

Task shifting to medical assistants, nurses & PLWA’s

“Partial” task shifting
to medical assistants
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
 Total placed on ART 1634

Community care Community care

YES NO Relative
Placed on ART (n-1634) 895 739 Risk:

 Alive & on ART 856 (96%) 560 (76%) 1,26

P<0.001 [1,21-1,32]

 Died 31 (3.5%) 115 (15.5%) 0,22

P<0.001 [0,15-0,33]

 Loss to follow up 1 (0.1%) 39 (5.2%) 0.02

P<0.001
[0 - 0.12]

 Stopped 7 (0.8%) 25 (3.3%) 0.23

P<0.001
[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
 Burkina Faso:
– Towards patient groups and associations
– Drug supply also in community?
– Not a high prevalence context
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