Transcript Taskshifting - Governance in Africa

Governance for Health Systems Development Conference
Moevenpick Hotel, Dar es Salaam
18th-22nd July 2011
Task Shifting
Presented by:
Dr. Peter Ngatia
Director for Capacity Building, AMREF
Monday, 20th July 2011
Human Resources for Health: Who?
Human Resources for Health (HRH): The stock of all individuals
engaged in promotion, protection or improvement of the health of the
population
Also referred to as: the health workers; the health workforce
A simple message:
health workers save lives!
HUGE Burden of Disease: Few Resources
Africa's Share of the World's
Population
11%
Africa's Share of the World's Disease
Burden
25%
Africa's Share of the World's Global health
Expenditure
2%
89%
75%
Africa
The Rest of
the World
Africa's Share of the World's Health
Workforce 3%
97%
98%
Africa's Share of the World's
Global
Health Expenditure
2%
98%
Distribution of health workers by level of health
expenditure and burden of disease, by WHO region
Workforce low,
Disease Burden high
Workforce high,
Burden low
Estimated critical shortages of doctors, nurses
and midwives, by WHO region
Africa has the least density
Countries with a critical shortage of health service
providers (doctors, nurses and midwives)
36/54 are in subSaharan Africa
The same countries are making slow
progress towards the health-related MDGs
Maternal mortality ratio per 100 000 live births in 2000
Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health Organization
Tanzania
• Like most other developing countries- faced with multifaceted
problems and challenges in the provision of health care.
• A shortage of skilled workforce stands out as one of the most
critical matter which affects health services delivery
• Currently, the total available health workers to provide required
health services are only 32,562 (40%) of the requirement. The
effort by Government in recruiting health Workers has resulted
in the reduction of gap from 68% in 2001 to 60% in 2010.
• There are still challenges with continuous professional
development in order to ensure that the few health workers
available increase in competence and deliver quality health
services
Distribution of existing health cadres (Tz)
HRH BY GROUP OF CADRES
Social w elfare,
238, 0.5% Support Staff, 940,
Nurses, 8223,
2.0%
17.3%
Allied Health
Non - Health
Professionals,
666, 1.4%
Medical
attendants, 15896,
33.4%
Professionals,
15702, 33.0%
Clinicians, 5962,
12.5%
Solution 1: Increase number of health workers
• Training more numbers of health workers
•Improve education system for more candidates
eligible to train for all cadres
•Invest in infrastructure for training facilities for
all cadres of health workers
•Invest in innovative training methodology
Solution 2: Retaining health workers
•
•
Improving the health workforce wages
Increasing deployment of health workers
•Increase the budgetary allocation
for health to cover better wages
•Have the workforce with the correct
skills deployed at all levels
•Increase the wage bill for health
workers
A case of TASKSHIFTING
•
A true story is told of an orthopaedic surgeon, one of very
few who practiced in 1970s who, although a brilliant
surgeon, had a major weakness for alcoholic beverages that
often caused him to fall asleep in the middle of an
operation. Nevertheless, his patients were also wheeled
out of the theatre with the operations having been done
perfectly. It turned out that his assistant, an old man called
Karuri who had for many years watched the surgeon at
work, handing him scalpel and forceps and sutures, took
over whenever his boss nodded off, doing everything
exactly as he had seen the surgeon do countless times.
Karuri took over the tasks of a trained health professional
and did them perfectly well. This is a simple case of
TASKSHIFTING.
Solution 3: Use health workers that
exist efficiently and effectively
• Task shifting
This is the rational re-distribution of tasks,
where appropriate from highly qualified
health workers to health workers with a
shorter training and fewer qualifications to
make efficient use of existing human
resources. (WHO)
Accepting task shifting as a plausable
solution to the HRH crisis?
•
In 2007 consultation of national governments, civil
society, professional organisations and international
organisations on task shifting as a solution for global
health worker crises.
•
In 2007 the task shifting project was underway with
selected countries—Ethiopia, Haiti, Malawi, Namibia,
Rwanda, Uganda and Zambia implementing the taskshifting approach for HIV service delivery with notable
success.
Towards a framework of task shifting
• 1st Global conference on task shifting
was convened in
January 2008 by WHO. Treat train, retain for HIV
• Guidelines and recommendations for task shifting were
formally launched to facilitate the widespread
implementation of task shifting in countries that
choose to adopt the approach
Assumptions of task shifting strategy
• That there is under-utilised capacity among less
specialised health workers.
• That it is desirable and possible to change priorities or
roles of less specialised health workers to include tasks
from more specialised health workers, or
• That the number of less specialised health workers can
be increased to accommodate increased
responsibilities more cost-effectively.
Recommendations A: On adopting task
shifting as a public health initiative
Case study: Kenya medical training
institute training trend
Recommendation 1.
Task shifting should be
implemented alongside
other efforts to increase
the numbers of skilled
health workers
Production of HRH must ALSO be scaled up!
Recommendations B: Creating an enabling
regulatory environment for implementation
Recommendation 6.
Countries could pursue
a fast track strategy and
simultaneously pursue
long-term reform that
can support task shifting
on a sustainable basis
within a comprehensive
and nationally endorsed
regulatory
South Sudan
 Ministry of health developed
 The incorporation of task shifting policy
in the training of clinical officers enables
them to perform C-sections and below
the knee amputations.
Kenya’s Community health strategy
(CHS)
 Further defined the role of community
health workers with
• modalities for supervision through
CHEWs and
• compensation on performance of Ksh.
2000 per month
Recommendation C: On ensuring
quality of care
Recommendation 9
Countries should adopt a systematic approach to
harmonized, standardized and competency based
training that is needs-driven and accredited so that all
health workers are equipped with the appropriate
competencies to undertake the tasks they are to
perform.
Recommendations D: On ensuring
sustainability
Recommendation 14
While volunteers can make
a valuable contribution on
a short term or part time
basis, trained health
workers who are providing
essential health services,
including community health
workers, should receive
adequate wages and/or
other appropriate and
commensurate incentives.
Insert examples of barriers to this?
Recommendation E: On oganisation of
clinical services
Recommendation 16:
Countries should consider the different types of task
shifting practice and elect to adopt, adapt, or to
extend, those models that are best suited to the
specific country situation (taking into account health
workforce demography, disease burden, and analysis
of existing gaps in service delivery).
Example of roles shifted or shared?
Need: universal access to HIV
testing and treating
Action: shift from doctor monitored
therapy to nurse monitored therapy
for HIV/Aids treatment
Evidence: multiple studies show nurse
monitored therapy not inferior to
doctor monitored
Where: Rwanda, South Africa , Lesotho,
UK
Gap: Further studies to observe
management of advanced HIV
infection
Need to increase access to
obstetric care to reduce
maternal mortality
Action: emergency obstetric
care/surgery by clinical officers
/medical officers etc
Evidence: multiple studies show clinical
efficacy and economic value of task
shifting to clinical officers
Where: Tanzania, Mozambique, Malawi
Gap: Further studies on a lower cadre
providing skilled delivery
Barriers to task shifting
Professional protectionisms
• Doctors feel that they have many years of training and
not just anyone can do a doctors job.
• Nurses feel their profession is invaded by nursing aids,
community health workers
Professional boundaries and regulation
• Regulatory environment is permissive of task shifting
however the cadre has no legal protection for additional
tasks if anything was to go wrong.
USAID & ECSA-HC 2010
Barriers to task shifting (contd)
Poor worker salaries and working conditions
• Seen as a ploy by governments to avoid paying the
right people to do their rightful jobs.
Perceived focus on HIV and AIDS
• makes people view task shifting as another
initiative for and about HIV and AIDS which would
weaken the health systems.
Addressing challenges 1: Protection of
health workers
•
Health legislation or administrative regulation
“In Namibia a nurse cannot prescribe ART because they are
bound by the clause on medications they are allowed to
prescribe. If a nurse prescribes and something goes wrong
they are on their own.”
•
This situation can be addressed if professional
protectionisms is reduced and rules and regulations
encompass task shifting.
Addressing challenges 2: Protection of
people receiving treatment and care
•
Training framework and accreditation for task shifting
“In Uganda ‘ task shifting is happening on a wide scale
at various levels and in many forms”
•
Midlevel health workers are providing services out of
experience without formal training and guidelines.
•
Development of frameworks for task shifting would
provide for pre service and in service training for
competencies assigned to these health workers.
Contact
Dr. Peter Ngatia
Director, Capacity Building
AMREF Headquarters
Ph: +254 20 699 3208/9
Email: [email protected]