Transcript PEPFAR’s Efforts to Strengthen the Global HIV Healthcare Workforce Caroline A. Ryan MD, MPH Director, Technical Leadership Office of the Global AIDS Coordinator, Department of State AIDS.

PEPFAR’s Efforts to Strengthen
the Global HIV Healthcare
Workforce
Caroline A. Ryan MD, MPH
Director, Technical Leadership
Office of the Global AIDS Coordinator,
Department of State
AIDS 2012 - Turning the Tide Together
The President’s Emergency Plan
for AIDS Relief (PEPFAR)

PEPFAR I: 2003-2008
 Priority: Scaling-up HIV/AIDS treatment, care and prevention
 Challenge: Not enough health care workers HIV training
 Focus on in-service training to teach HIV skills to existing health
workers, task shifting/task sharing HIV services, and some integration
of HIV content into pre-service degree programs

Task shifting
 “Game changer” in scaling-up HIV treatment, care, and prevention
 Support for WHO Task-shifting Guidelines
PEPFAR II (2009-2014)

Priority: Health systems strengthening
 Country ownership and sustainability of HIV programs
 Congressional mandate to train and support retention of
140,000 new health care workers, with an emphasis on
doctors, nurses, and midwives

World AIDS Day 2012
 Recognizing critical role of nurses and midwives to meet
new targets:
• 6 million on ART
• 1.5 million pregnant women on ART
• 4.7 million voluntary medical male circumcision
PEPFAR’s HRH Strategy: Vision and Goals
Vision: Appropriate number and distribution of qualified health
workers who meet the HIV and other health needs of the
population
Goals:
• Increase the Density of Health Workforce
– Number
– Cadres
• Balance Distribution of Health Workforce
– Geographic location
– Sector
– Gender
• Improve Performance of Health Workforce
– Quality
– Efficiency
Health Labor Market Dynamics
Flow Chart Illustrating Various Points for Policy Intervention in HRH Labour Market
Health Care Education
Labor Force
Take-up Rate
Participation
Rate
Health Care Labor
Force Participation
Rate

Health
Care
Sector
High
School
Training
in
Health
Pool of
Qualified
HW
Employed
Unemployed
Other
Training
MIGRATION
USA, UK
Adapted from Marko Vujicic, World Bank 2009
NonHealth
Care
Sector





Geographic
distribution
Private/Public
sector
allocation
Absenteeism
Skill mix
Productivity
Quality
We need to maximize PEPFAR’s return on
investment in creating new health workers by
supporting critical components of the HRH
system
PEPFAR’s Human Resources for
Health Objectives
1. Strengthen pre-service education institutions
2. Ensure quality of in-service and pre-service training and
practicing professionals
3. Support the development of new cadres and strengthen the
community workforce
4. Improve health worker motivation and productivity and
foster positive workplace environments
5. Investigate and apply recruitment and retention
strategies
6. Improve HRIS and utilization of data for improved
management and planning
Objective 1
Strengthen pre-service
education institutions
New HCW
Students
Teachers and
Effective Leadership
Infrastructure
Source: ITECH
“Combination
Infrastructure
• Classrooms
• Labs
• Housing
• Septic and Utilities
Curriculum Development
• Updating
• Create new cadre
• Shortening programs
• Efficiencies (multi cadre)
Teachers and Management
• Recruitment
• Training
• Retention
• Continuing professional
development
Approach” to Pre-Service
Education
Materials
• Books
• Libraries
• Lab Supplies
• IT/internet
Practica/Residency
• Hospital space/practice
standards
• Clinical mentors
• Transport
Other
• Retention of students
• Planning & Management
• Prep in math & science
Objective 2
Ensure quality of inservice and pre-service
training and practicing
professionals
• MEPI/NEPI
• East Africa: multi-country learning
collaborative to strengthen
regulatory bodies and professional
associations
• Uganda & Tanzania: Evaluating
country in-service HIV/AIDS
training programs
• Global: twinning partnerships in
ten countries in Africa and Russia.
Objective 3
Support the development of new
cadres and strengthen the
community workforce
• WHO: Task-shifting guidelines
• Mozambique & South Africa:
Development of new cadres
• GHWA: Community Health Workers
study
• Global: Community Health Worker
Program Assessment and Improvement
Matrix (CHW AIM)
African Health Profession Regulatory
Collaborative (ARC)

Four-year initiative to strengthen nursing and midwifery leadership
and regulation in 17 sub-Saharan African countries

Objectives





Ensure high quality practice standards
Ensure updated regulatory frameworks
Strengthen nursing and midwifery councils
Cultivate African nursing leadership
Approach





Regional conferences
South-to-south collaboration
Regulation improvement grants
Targeted technical assistance
Evaluation science
Objective 4
Improve health worker
motivation and
productivity and foster
positive workplace
environments
Figure 1. Uganda Productivity:
Average Client Waiting Times in Kabuyanda Baseline and Follow-up
Average Client Waiting Times in Kabuyanda at Baseline and Follow-up
Average waiting time at baseline
Average waiting time at follow-up
198
200
180
160
Average time (minutes)
• Zanzibar & Tanzania: Productivity
& Work Climate Study
• Niger, Uganda, & Tanzania: HRH
Collaboratives
• Swaziland & Uganda: Wellness
Centers for health workers
• Rwanda : national performance based incentive scheme
143
140
120
100
80
61
60
40
48
26
31
20
29
7
0
Registration & triage
Consultation
Dispensing
TOTAL
Clinic service
* The average waiting time for 'Consultation' at follow-up is a weighted average of 'Consultation with nurse' and 'Consultation with clinician'
Objective 5
Investigate and apply
recruitment and retention
strategies
• WHO: Retention recommendations
for increasing access to health
workers in remote and rural areas
• Mozambique & Swaziland:
Retention & Quality of Services
study
• Tanzania: Recruiting health
students from rural areas
• Global: Developing
recommendations for measuring
retention in PEPFAR countries
Objective 6
Improve HRIS and
utilization of data for
improved management and
planning
• Global: Implementing iHRIS (open
source software) in 14 countries
• Kenya: Public Health HR Information
System and Workshop being
expanded for use in other countries
• Uganda: Work with MOH & MOF on
resource planning
• Global: HRM Rapid Assessment Tool &
Curricula development
From: “Zeroing In: AIDS Donors and Africa’s Health
Workforce” – Oomman, Wendt, Droggitis. Center for
Global Development. August 2010
Expanding the Evidence Base:
Research & Innovation
• Tools
–
–
–
–
HRH Action Framework (http://www.capacityproject.org/framework/)
Rapid Discrete Choice Experiment (DCE) Tool
Employee Engagement Tool
TrainSMART
• Implementation Science
–
–
–
–
Impact of task-shifting on ART delivery (multi-country)
Effectiveness and attrition of providers in PEPFAR-funded health centers (Ethiopia)
Study on Success Factors for Management Capacity Building Sustainability
Impact of Task Shifting for ART Delivery on Patient and Process Outcomes in
Uganda
– Nurse-initiated and managed HIV Treatment in Policy, Education, and Practice in 17
African countries
– Measuring the Impact of On-Site Mentorship on Nurse and Clinical Officer’s HIV
and TB Care and Competencies
– Descriptive Study of Nursing and Midwifery Practice and Education Regulation in
East, Central, and Southern Africa
Considerations Going Forward
• An appropriate balance between ‘quantity and
quality’.
• Multi-sectoral approaches, particularly
between health and education sectors
• Long term, sustainable changes in areas of
recruitment, education/training, and
retention.
• The use of evidence-based information with
demonstrated effectiveness in LMIC.
• Affordable in LMIC.
Acknowledgements
• The PEPFAR HRH Technical Working Group
–
–
–
–
–
–
Estelle Quain, USAID
Alexandra Zuber, CDC
Jessica Rose, USAID
Diana Frymus, USAID
Margaret Brewinski-Issacs
Myat Htoo Razak
Thank You
For further information, please visit:
www.PEPFAR.gov
www.facebook.com/PEPFAR
http://twitter.com/USPEPFAR
The Medical Education
Partnership Initiative (MEPI)
Fitzhugh Mullan, MD
Seble Frehywot, MD, MHSA
Francis Omaswa, MBCHB, MMed, FRCS, FCS
-- Co-Principal Investigators
AIDS 2012 - Turning the Tide Together
PEPFAR and
Medical/Nursing Education
•
•
•
•
Complexity of HIV/AIDS treatments
Health system requirement
No health workers = no system
Community health workers are necessary but
not sufficient
• Medical doctors and nurses are essential to a
stable, functional system
MEPI Structure
•
•
•
•
PEPFAR/NIH/HRSA supported
$130 million investment over five years
13 medical schools in 12 countries
32 African, 17 American, 2 British and 1
Canadian partners
• Coordinating Center – GW Department of
Health Policy/African Center for Global
Health and Social Transformation (ACHEST)
MEPI Aims/Themes
• ↑ Medical education capacity (quantity and
quality of graduates)
• ↑ Retention and geographic distribution of
graduates
• ↑Regionally relevant research training
The MEPI Landscape: Common
program areas
MEPI Technical Working Groups
•
•
•
•
•
•
E-learning
Community based practice
Research Support Centers
Tracking
Competency based practice
Medical Education Research
Areas of success
•
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•
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Annual Symposium
PI Council
Networking, collaborating, organizing
Focus on medical education, locally
Focus on regional medical education
Curriculum review and revision
Faculty development
Enhanced research training
Areas under development
• Educational Capacity Enhancement
– Improved educational quality
– Links to new schools
• Retention
– Tracking
– Distribution
• Sustainability
Visit us…
http://mepinetwork.org
NEPI Coordinating Center: Breaking New
Ground with Nursing and Midwifery Education
Jennifer Dohrn DNP, CNM
Project Director, NEPI Coordinating Center
ICAP Global Nursing Capacity Building Program
Columbia University, New York
AIDS 2012 - Turning the Tide Together
Remembering Those Who Walked Before Us
PEPFAR
NEPI Goal
• Increase quality, quantity and relevance of graduating nurses
and midwives through strengthening nursing and midwifery
education institutions
– Nursing and midwifery education is the foundation for building corps of
nurses and midwives who are:
• competent in knowledge and clinical skills
• competent in health systems strengthening
• competent in leadership – of the multidisciplinary facility team and of
the country level health planning team
– Nurses and midwives are the frontline providers in most African countries
Nurses and midwives are the frontline providers in most
African countries
HRH
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
N&M (% TWF)
Doctors (% TWF)
Unique Foundation of NEPI
• Governance by Ministries of Health/Education
• NEPI is positioned in context of country’s needs for nursing and
midwifery education and
• From the start, part of national health plan for HRH and HSS
• MOH/E determine nursing education interventions and select 36 schools per country for intervention
• Maximizes coordination
• Maximizes contributing to national health strategy
• Provides coordination, communication, enabling environment, sharing
collaborations and harmonization, sharing of best practices, unified
monitoring and evaluation framework
• Pathway to sustainability and replication, within country and
across countries
NEPI CC: Our Steps in Each Country
• Assess (with partners) to identify and prioritize needs
• Form NEPI Advisory Committee or Working Group
– Led by MOH/E
– Includes USG in-country, nursing education institutions, stakeholders
• Select nursing/midwifery schools and interventions based on:
– Assessment findings, input from NEPI Advisory Committee/Working
Group, in synergy with national HRH strategy
– Identified and prioritized needs
– Greatest impact for improved health outcomes
– Sustainability
– Ability to replicate and expand
• NEPI CC:
• Supports and coordinates interventions
• In collaboration with MOH, MOE, OGAC, HRSA, in-country USG, nursing and
midwifery institutions, and other stakeholders
– Subcontracts with nursing/midwifery schools as mechanism for providing
PEPFAR funds to schools
• Monitors and evaluates
– Conducts M&E with nursing/midwifery schools with on-going presentation of
findings and adjustments to maximize interventions
• Develops exchange across country programs and across the
region:
• Technical assistance, regular communication, larger forums, newsletter,
website, summit meetings
• Builds relationships with African-based nursing and midwifery
expertise
• Represents NEPI at global forums WHO Transformative Health
Professionals Guidelines
NEPI CC: Cross-Country Challenges in Nursing Education
•
•
•
•
Increasing numbers and capacity of nursing tutors
Increasing integration of clinical knowledge into curriculum
Upgrading programs for nurse midwifery training
Upgrading levels of nursing, with ability for bachelor and
advanced degrees
• Supporting Nursing Councils to implement transformational
nursing education standards and increased scopes of practice
All involve strengthening institutional capacity and retention
strategies for nursing profession
NEPI CC: Initiatives to Address Challenges
• Increasing numbers and capacity of nursing tutors:
– Increased enrollment in programs to produce tutors
• Malawi, Zambia
– Teaching methodology
• All NEPI countries
– Publishing, research
• All NEPI countries
– E-distance learning; distance-based curriculum modules
• All NEPI countries
NEPI CC: Initiatives to Address Challenges
• Increasing integration of clinical knowledge into curriculum
– Clinical Instructor program
• Malawi, Zambia
– High quality skills laboratories matched with needed competencies
• All countries
NEPI CC: Initiatives to Address Challenges
• Upgrading programs for nurse midwifery training
– Bridging midwife technicians to registered nursing (Malawi)
– Combined midwifery-nursing tracks (Zambia)
– Increased midwifery skills for nurses (Lesotho)
NEPI CC: Initiatives to Address Challenges
• Upgrading of levels of nursing, with ability for bachelor and
advanced degrees
– Career advancement opportunities (to Bachelor’s and Master’s degree)
• Malawi, Zambia
NEPI CC: Initiatives to Address Challenges
• Supporting Nursing Councils to implement transformational nursing
education standards and increased scopes of practice
– Provide technical expertise in development of national
nursing/midwifery educational standards
– Explore the needs of Nursing Councils with respect to ensuring the
relevance and quality of nursing pre-service competencies and level
outcomes, the pre-service scaling-up process, and mechanisms for
accreditation
• All countries
Summary of NEPI interventions
The Way Forward
University of Nairobi MEPI Project
PRIME-K
Overview and Activities
James N. Kiarie
AIDS 2012 - Turning the Tide Together
Background
• Mission: To Improve Health of Kenyans Through
Research and Training
• Aims
– Improve Quality and Quantity of Training
• Innovative teaching techniques
• Decentralized training
– Increase conduct of Regionally relevant research
• Support research by faculty, students and adjunct faculty
• Develop Research administration and oversight capacity
The Implementation team
• Structure
– Advisory Board
– Aim leads
– Implementing teams
• Partnerships
– University of Washington, Seattle (UW)
– University of Maryland, Baltimore (UMB)
– Kenyatta University (KU)
– Kenyatta National Hospital (KNH)
Set UP
PRIME-K Advisory
Board
Principal Investigator
UW and UMB teams
Lead and Aim 1 team
Lead and Aim 2 team
Lead and Aim 3 team
Lead and Aim 4 team
PI and Linked award team
Project Manager
Training coordinator
M&E/ Manager
Accountant
Administrator
Assistant administrators
IT officer
Driver
Strengths of University of Nairobi Program
• College wide activities in schools of Public Health,
Medicine, Nursing and Dental Sciences
• Close collaboration with the Ministry of Health
• Emphasis on M&E and measurable outputs
• Involvement of top University Management
Key activities
• Improve Quality and Quantity of Training
– Innovative teaching techniques
– Decentralized training
• Increase Regionally relevant research
– Support research by faculty, students and Adjunct
Faculty
– Develop Research administration and oversight
capacity
• Monitoring and Evaluation
Innovative teaching techniques
• New Training Initiatives
– SON – Upgrading diploma nurses with AMREF.
– BSc Medical Laboratory Science and Technology
• Curriculum review support
• Faculty Training
– 44 trained on innovative training methodology
– 3 day training with ½ day on use of IT in training
• Development of Library
– 50 computers purchased
– Renovating room
• Development of skills lab
Decentralized training
• Decentralized training sites
– 4 in year 1 (Coast, Naivasha, Mbagathi, Garisa)
– 5 in year 2 (Kitui, Karatina, Busia, Kisii and Pumwani)
• Student Training /supervision
• Strengthening data systems in decentralized sites
– Systems stronger than envisaged
– Shortcomings in inpatient, use for reporting and use
for decision making
• Distance education
Training Sites and Students
•
•
•
•
29 medical students did 8-week rotations
6 pharmacy students did 6-week rotations
20 dental students did 2-week rotations
20 nursing students did 4-week rotations
Research by Faculty, Students and
Adjunct Faculty
• 5 Implementation Science Fellows admitted
• 1 Career Development project funded
• Role of Endogenous and Exogenous Female Sex Hormones
in HIV-1 Shedding
• 12 Mentored Seed Projects
• Factors influencing nursing research at KNH and Aga Khan
University Hospital in Kenya
• integrating screening and management of GBV into
antenatal and post natal care
• disaster preparedness in health facilities in Nairobi County
• Impact of KNH lactation management training program
on infant and young child feeding practices
Research Administration and Oversight
Capacity Development
• Compliance with funding
– Draft Strategic plans for UoN grants finance management
and UoN/KNH ERC developed in year 1
– Follow up workshop planned for ERC SP
– GFM SP awaits approval
– Planned visits to Malawi and UW for benchmarking
• Certificate in bio ethics by ERC
– Course planned
• Training in RCR
– 43 participants trained from UoN, KNH, KU, MoH and Moi
University
• Grants Management Software
– Committee appointed by VC to determine the requirements
Monitoring and Evaluation
PRIME-K website
• http://www.uonbi.ac.ke/projects/pimek/
• >10,000 hits to date
Home
About Us News
Collaborations
• Home page
Opportunities
e-Resources
– Pictures
– Mission
Our Mission
– Project Overview
•
•
•
•
News
About us
Collaborations
Resources
Activities
Contact Us
Project Overview
Mission PRIME-K shall improve health outcomes in Kenya through medical education and clinical research in
partnership with the University of Washington (UW) and the University of Maryland Baltimore (UMB). This is in
line with the mission of the University of Nairobi (UoN) to provide quality university education and training and
to embody the aspirations of the Kenyan people and the global community through creation, preservation,
integration, transmission and utilization of knowledge. PRIME-K will contribute towards achievement of Kenya
Thank You
PEPFAR
Nursing Education Partnership Initiative
in sub-Saharan Africa:
Collaborative Actions
Lyn Middleton (RN; PhD)
Regional Nursing Advisor
NEPI Coordinating Center
ICAP, Columbia University, New York
& University of KwaZulu-Natal, South Africa
AIDS 2012 - Turning the Tide Together
Perspective
1. Threads from the tapestry of
nursing and midwifery that
have inspired the NEPI in DRC,
Ethiopia, Lesotho, Malawi,
Zambia
2. Ideas for how PEPFARs Nursing
and Medical Education
Initiatives might turn the tide
on inter [intra] professional
collaboration
African threads
Health trends and
expectations of
people for reliable,
accessible and
affordable care and
comfort across the
life-span
1.
Commitment
• Country
• Local, regional and global nursing and midwifery
community (education, service, research, advocacy)
• Development partners
Nursing Education in Africa
WHO African Region Meeting
23 representatives , Uganda, 1953
(AJN, 1954)
2.
Ownership for development
Country-led
Donor-led
“Between 1953 and 1966, 29
USAID nurse advisors
provided 128 years of
technical assistance to
nursing in Ethiopia.”
Historical survey of the US
Technical Assistance to Nursing
between 1943-1966, AID.
“Through the Medical and
Nursing EPIs, PEPFAR is
supporting countries in
developing sustainable local
capacity to produce skilled
doctors, nurses and
midwives for generations to
come.”
Amb. Eric Goosby, US Global Aids
Coordinator, 25 June 2012.
Country ownership is principally about building capacity to set priorities, manage resources,
develop plans, and carry them out.”
Hillary Rodham Clinton, Secretary of State, June 1, 2012
3.
The visibility of the N and M workforce
HRH
N&M (% TWF)
• N&M site of and
resource for
health systems
strengthening
• Strengthening
components of
the nursing and
midwifery
education
systems
Doctors (% TWF)
87.4
56
54.8
53.1
50.7
41
31.7
27
9.7
11.1
4
World
WHO A Reg
DRC
Ethiopia
3.3
3.2
3.1
Lesotho
Malawi
Zambia
4.
•
•
•
•
Nursing and Midwifery Education in the
NEPI countries
Complex landscape
Differences between Anglophone & Francophone countries
NEPI informed by local and regional knowledge
NEPI contribute to this knowledge base in each country
CHAI (Clinton Health Access Initiative )
Cplus (CapacityPlus, USAID)
Summary of NEPI interventions
Collaborative actions:
NEPI-MEPI
Inter-professional Education and Collaboration
• Inter [and intra] professional boundaries
integral to history of professional care
processes
• Boundaries as conditions for communication,
exchange, bridging
• Boundary objects e.g. strategies and
techniques for improving professional
practice and health care outcomes
Inter-professional Education and Collaboration in
the NEPI-MEPI countries
Conclusion
• N and M site and resource for health systems
strengthening
• Pre-service education with clear career pathways and
opportunities for on-going professional advancement
• PEPFAR’s N&MEPI are powerful demonstration sites for
inter-professional collaboration in education and
practice
• Boundary contours flexible enough to respond to local
forces and evidence yet robust enough to maintain
professional identities
• Needs-based, accessible and affordable care
• Ensuring reasonable health for more people across the
life-span