What aspects of task shifting are working well and can we build upon and replicate these achievements in Uganda?

Dr Shafique Pirani University of British Columbia Project Director Uganda Sustainable Clubfoot Care Project

Problem - A global health workforce crisis • • • • World facing a chronic shortage of trained health workers. Global health workforce deficit of more than four million Shortages critical in developing nations Malawi - one doctor for every 100,000 people.

Task Shifting - Global Recommendations and Guidelines, WHO 2006

• • • Problem - A global health workforce crisis Direct correlation between numbers of people with access to health services and the numbers of health service providers. Crisis impedes ability for “enough people, with the right skills, in the right place” Need to strengthen health systems to meet commitments of Millennium Development Goals Task Shifting - Global Recommendations and Guidelines, WHO 2006

Task shifting “A rational redistribution of tasks among health workforce teams whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications so as to make more efficient use of existing human resources and ease bottlenecks in service delivery.” Task Shifting: A Strategy to address the problem of a chronic shortage of trained healthcare workers Task Shifting - Global Recommendations and Guidelines, WHO 2006

Task shifting not new

Many nations have a history of health care provision by staff who are not trained to be physicians, but who are capable of many of the diagnostic and clinical functions of medical doctors.

Officiers de sante (France) Feldshers (Russia) Barefoot doctors (China)

Orthopaedic Clinical Officers, Malawi Orthopaedic Officers, Uganda

Non specialist surgeon Medical Officers at District Hospital without Surgeon ? Safe ? Effective ? Cost ? Sustainable Non-physician surgeons Technicos De Cirugia Nurses who have 3 yrs additional training in a program established in 1984.

• • • 2071 caesarian deliveries 46% by assistant med officer 54% by specialists • • • No differences in the indications for caesarean delivery No differences in interventions associated with caesarean delivery Significant difference in superficial wound separation due to haematoma, which was slightly more common (0.35% vs 0.05%) in the group operated on by assistant medical officers

• • • • 14 assistant medical officers (1995) 10,258 surgical operations 70% emergency (0.4% postoperative mortality) 30% elective (0.1% postoperative mortality) After 7 years • >90% of three graduating classes of tecnicos de cirurgia stayed in rural areas • Not a single physician graduating in the same years did so. Pereira et al (unpublished)

Productivity And Costs 2002

Surgeries Number of surgeons C-sections per surgeon Obstetric Hysterectomies per surgeon Laparotomy per surgeon Cost per surgery 6 $144

Specialist Surgeon Non-Physician Surgeon (technico)

5264 47 102 4 6914 53 117 7 7 $39

• Define Limits • Provide Training, Supervision and Referral Systems • Ensure Adequate Recognition and Remuneration • Develop Adapted Guidelines • Simplification • Engaging with Regulatory Frameworks and Professional Bodies • Exploring Potential for Community Support Guidelines for Task Shifting (borrowed from HIV/AIDS)

“To contribute to eliminating the neglected clubfoot as a significant cause of musculoskeletal disability and poverty in Uganda”

Good/Ex cellent 33% Fair/Poor 67%

Reoperation rate 88%

The Ponseti Method

Dr Ignacio Ponseti University of Iowa

Ponseti

Good/Ex cellent 78% Fair/Poor 22%

Controls

Good/Ex cellent 85% Fair/Poor 15%

Task Shifting – Paramedicals can treat clubfeet

“… the Ponseti method of serial cast treatment can be employed successfully by appropriately trained healthcare professionals such as physiotherapists…”

Task Shifting – Paramedicals can treat clubfeet

“ We believe that the Ponseti technique is suitable for us by non-medical personnel….”

Engaging Regulatory Frameworks and Professional Bodies Training and Supervision

Define Limits, Develop Adapted Guidelines Institutions Teaching Medical Schools Paramedical Schools Nursing & midwifery Schools 4 2 32

Referral System

Screening for foot deformity at birth Clubfoot clinics in 36 hospitals Opening Arua Hospital Clubfoot Clinic

Exploring Potential for Community Support: Ethnocultural survey of clubfoot in Uganda

‘Traditionally, people think that there are unappeased spirits causing the problem.’

Practitioner treating clubfoot

‘ I absconded from treatment because the kids father provided no support’

Mother

Clubfoot clinics in 36 hospitals Children treated per year by region Region Central Eastern Norther n Western Total 2006 155 116 32 106 409 2007 2008 2009 171 209 232 144 35 175 54 205 92 135 485 170 608 204 791

Ex Africa Semper Aliquid Novi

There is always something new from Africa

Pliny the Elder, 77AD.