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Vienna IAS conference, July 2010 Mit Philips, MD, MPH. Human ressources for health: the ultimate bottleneck ? . Reduce & delegate clinical tasks in HIV care Lessons learned (Southern Africa) Patient outcomes & safety - PowerPoint PPT Presentation
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Human ressources for health: the ultimate bottleneck ?
Vienna IAS conference, July 2010Mit Philips, MD, MPH
Reduce & delegate clinical tasks in HIV care Lessons learned (Southern Africa) Patient outcomes & safety Enabling factors: training, clinical mentoring, quality control,
incentives
Psychosocial care Drug supply & dispensing System change Beyond reducing the need for health workers
Human resources for health care and ART
How to deal with shortfall?• Increase health workforce and its output
•Retain, including Treat•Produce, including pre-service training or import•Recruit into the care system•Distribute equitably, according needs
• Decrease need for health worker time
Decrease need for health worker time
Clinical tasksWhat tasks need clinical expertise/which not ?What patients need clinical expertise/which not?What stages need clinical expertise /which not?
Psycho-social support Drug supply & dispensing Lab tests
VCT OI Prophylaxis
Post -initiationIRISStage I,II Stage III,IV
HAARTFollow-up
Long term ARTComplications
Critical moments in clinical tasks
Initiation
Task shifting in Thyolo, Malawi
« Universal access» (district 600.000 inhab) Without it much slower roll out
Without it need to absorb extra nurses; large proportion of annual graduation
Without it saturation ART clinic Without it decentralisation to Health Centres not possible
0
50
100
150
200
250
300
350
400
2004 2005 2006 2007 jun/08
Hcentres
Hospital
“Partial” task shifting to medical assistants
Task shifting to medical assistants, nurses & PLWA’s
ART initiation In 7 health centres (MAs, nurses, HSA)
1
1 22
3
3
New patients enrolled per month (initiation ARV) in Thyolo
Are patient outcomes and safety the main concern ?
Thyolo district experience: Outcomes : survival & loss to follow up Care closer to home: adherence & continuity improved
Randomised proof:
Hospital (n-2904)Retained 2463 (84.9%) Alive 2384 (82.1 %) Transfer out 79 (2.7%)
Health centres (n-1170) Retained 999 (85.4%) Alive 994 (85 %) Transfer out 5 (0.4%)
Psycho-social support
Lay workers versus nursesLay counsellors
Lesotho, Malawi (HSA), South Africa
Difficulties: Creation of new cadres
(Mozambique) Wage bill restrictions (civil
servants) Legally allowed to perform
HTC including pricking blood, exceptions: Moz & Zim
Government reluctant to counselling by non-medical staff. Pilot: Adding lay counselors for ART initiation
in health centres, Mozambique
cART INITIATION IN CHIUTA
5 64
7
11
1
6
3 2
97
3
64
15
19
12 12
21
0
5
10
15
20
25
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2006 2007 2008
n pa
tient
s
Arrival of Lay Counselors
Enabling factors
Training and clinical mentorship (on site)
Ongoing monitoring Supportive supervision Referral unit for
problematic cases Telephonic support Treatment literacy
Challenges & tensions
Mid-level cadre (medical assistant, nurses, pharmacist assistants) Legal protection (South Africa,
Zimbabwe) Career path Retention and motivation
CHW ( HSA, counselors, expert patients) Clinic based ? or community based New level of cadre? Source of payment? Polyvalence versus competence Turn-over and re-training
Review system beyond task shifting
Cancel tasks (superfluous)- Streamline patient circuit - Simplify, simplify, simplify
Frequency of patient- health facility contacts Clinical Drug pick up Study Malawi: most reduction HRH needs by reduced visit freq
Keep patients without clinical needs out of the health facilities Time and cost to patients: adherence down Health workers’ time Nocosomial infection risk
Drugs supply & dispensing
De-link dispensing from clinical care
Task shifting to pharmacy assistant
Out-of facility community meeting points: Malawi: outreach clinics South Africa: dispensing units send
drugs to patients (cfr chronic disp unit) Mozambique: community ART groups
Legal constraints prescription
Where are the limits ?• Nurses to initiate ARVs in children?
Rwanda: <4% mortality at 12 months in a cohort of 312 children• Lay workers to manage stable patients without complications?
Malawi + Lesotho• Home-based ART?
Home-based ART and CTX associated with > 90% mortality reduction in rural Uganda (Lancet 03/08)
• Lay workers to dispense ARVs?Malawi
• Lay workers to initiate ARVs
• Patients manage their drug supply and come into health facility only once every….
How much progress since Mexico 2008 ?
Tension: results on short term and long term measures
Remember this?
Mexico IAS Conference 2008MSF Satellite meeting:
« Mind the gaps »
Task shifting helps…… but more qualified health workers needed
Need for Retention => improve working conditions & salary
Healthworker crisis
Recent HRH measures Import health staff
E.g. Malawi, Lesotho
ARV care for staff Re-integrate retired nurses
E.g. Mozambique, Malawi, Tanzania, S.A
Re-integrate diaspora E.g.Lesotho, Malawi
Increase salaries through GF & other funding E.g. Malawi, Lesotho,
Reinforce pre-service training E.g.Lesotho, Malawi, Mozambique
Malawi Emergency Plan (EHRRP)6 years, US$ 270 M
1. Expanding domestic training capacitiestutors and infrastructure
2. Recruitment and retentionrecruitment galas, 52% top-ups of salaries, bonding, rural hardship incentives, staff housing
3. Stop-gap measures import doctors and nurse tutors (VSO and UNV)
4. TAs for planning and management capacity/skills development MoH and financial support for regulatory bodies
5. Improved monitoring & evaluation HR capacity (linked to SWAp M&E framework)
6. Funded by GFATM & DFID: Sustained funding?
Malawi EHHRP: results
• Information on measures difficulty to reach district• Challenges to measurement
• Availability >> where?
• Yesterday, we heard from Frank Chibwandira, Malawi: Increase number health workers available• Lab and medical assistants to +/- 200%• MD, Clinical Officer to > 200%• Nurses to 140%• HAS (lay workers): +10.000
?? Who’ll pay to assure continuity
HRH: Still the major bottleneck?
Not much change in expanding HW force- Same bottlenecks, with a few exceptions:
barriers to recruit additional health staff as civil servants as non-civil servants
barriers to recruit lay workers Salaries frozen at too low levels to retain, no budget for new posts, No new cadres No dissemination of exceptions' successes cc wage bill Legal and other barriers in allowing task shifting Delivery models insufficient change: systems resistant to change
eg. supply & dispensing
Worse ahead?
Donors backtracking on recurrent costs•Back to nurses without drugs?• Additional nurses trained- but no money to recruit them?• Funding for complementary workforce (NGOs, lay counsellors, supervisors of lower cadres) to be reduced?• Increased need for clinic-time and clinician-time:
•Task shifting impossible due to rationing as patients will be more ill; decentralisation blocked•Cheaper treatment options more secondary effects•Funding uncertainty knock on effect on supply & adherence >> workload increase (patient frequent return & tracing defaulters)
THANK YOU
HSS