Impact of HIV scale-up on health workforce dynamics: opportunities for rethinking traditional roles and concepts

Uta Lehmann, School of Public Health, University of the Western Cape

IAS pre-conference meeting: Accelerating the Impact of HIV Programming on Health Systems Strengthening

17/18 July 2009

Outline Key factors impacting on the health workforce

Increasing demand through sicker populations

Fewer professionals

Strong civil society response

New mid-level and community-based cadres

Health sector reform

Policy responses Increased production

Task-shifting and renewed interest in community participation and the use of lay personnel (often post hoc)

Increased interest in the softer issues of HRH: staff motivation, leadership, power, etc.

Policy and evidence gaps

1. Example of increasing demand I:Causes of adult mortality region, 2004

0 2 4 6 8 10 12

Africa

Europe

South East Asia

Eastern Mediterranean

Americas

Western Pacific

High income

Death rate per 1000 adults aged 15–59 years

Cardiovascular diseases

Cancers

Other noncommunicable diseases

Injuries

HIVAIDS

Other infectious and parasitic diseases

Maternal and nutritional conditions

Source: WHO, Global burden of disease update.

Example of increasing demand II:Change in disease burden:

Changes in TB disease burden 1998 - 2008

0

200

400

600

800

1000

1998 2003 1998 2003 1998 2003 1998 2003 1998 2003 1998 2003

Angola Botswana Ethiopia Ghana South Africa Tanzania

Incidence oftuberculosis(per 100 000populationper year)Prevalenceoftuberculosis(per 100 000population)

Source: WHOSIS data

Example of delivery gap in South Africa:

2. Fewer professionals:

Staff numbers in public sector (which serves around 85% of population) in South Africa: 10,000 doctors (30% of those registered) 45,000 professional nurses (42% of those registered) 21,000 enrolled nurses (52% of those registered) Around 40,000 lay health workers

Vacancy rates in the Public Sector – South Africa(% of existing posts vacant)

2006 2008

Medical practitioners 29.9 34.9

Professional nurses 31.5 40.3

All health professionals

27.2 35.7

Source: SA Health Review 2008, Chpt. 16

3. Strong civil society response

CBOs, faith-based organisation, NGOs involved in various aspects of advocacy, treatment, care, etc.

So, less professional personnel available, but large numbers of para-professional and lay personnel:

Provincial health departments in South Africa employ close to 40,000 CHWs through 1,636 NPOs. In comparison, in 2008, the public health sector employed 48,000 professional nurses

4. Proliferation of new tasks and new cadres participating in health care delivery

TASKThyolo Scott HSA Nohana Lusikisiki Khayelitsha

Health education

community volunteers

lay counsellors

village health workers (VHWs)

community support group

adherence counsellors

Support groups

community volunteers

lay counsellors

VHWs community support group

adherence counsellors

Pre- & post-test counselling

health surveillance assistants (HSAs)

lay counsellors

community care givers

lay counsellors

Follow-up counselling & support

HSAs lay counsellors

VHWs adherence counsellors

adherence counsellors

Adherence counselling

lay counsellors

VHWs adherence counsellors

adherence counsellors

General facility support[1]

lay counsellors and VHWs

adherence counsellors

clerks and nursing assistants

Testing nurses and HSAs

lay counsellors and nursing assistants

adherence counsellors

nurses

Staging nurses and medical assistants

nurses nurses nurses nurses

Treatment of opportunistic infections

nurses nurses nurses nurses nurses

ARV initiation & management

nurses nurses nurses nurses doctors

DOT-HAART VHWs

Defaulter tracing

community volunteers

lay counsellors

VHWs Adherence counsellors

Adherence counsellors

Chronic care management

nurses Nurses

5. Health sector reform:

Particularly in South Africa these developments occurred in conjunction with health sector reform initiatives which have lead to an unprecedented deterioration of relationships and trust in the services.

Following four slides courtesy of Lucy Gilson – many thanks!

‘They fail to deliver on promises which they make.

They expect us to deliver and yet they are not delivering... I don’t trust them.’

(in-depth interview, auxiliary nurse)

Exploring the influence of workplace trust over health worker performance in South Africa, 2004.

‘It will take a long time for the broken trust to heal. We’re waiting to see what happens and we will not go unheard again’

Dr Rapise Malatji, United Doctors’ Forum:

‘Let down by govt let down by SAMA’.

Mail & Guardian May 1-7 2009: p.10

‘It looks as if the work we do is not enough and the management does not appreciate whatever we do

and thus the nurses become less motivated…. I think due to frustration of what the nurses go through

with their work, they express their anger by becoming nasty to the patients…’

(in-depth interview, professional nurse)

Exploring the influence of workplace trust over health worker performance in South Africa, 2004.

So what have been key policy responses?

Increased production Task shifting and renewed interest in

community participation and the use of lay personnel (often post hoc)

Beginning, but as yet fairly unsystematic interest in the softer issues of HRH: staff motivation, leadership, power, etc.

Increased production:Yes, but …

WHO estimates that the WHO African Region has a shortfall of 817 992 doctors, nurses and midwives => need to more than double the workforce among these professional categories.

It takes six years to train a new doctor, three or four to train a nurse and four to train a midwife.

Moreover, current training facilities are insufficient to meet the need fast enough.

The medical schools in continental Africa currently turn out only 5,100 graduates per year, and many of these newly qualified doctors migrate to jobs abroad.

Task shifting and use of alternative cadres:

Reviews of evidence consistently show that delegation of tasks, whether from doctors to non-physician clinicians, including nurses, from nurses to nursing assistants or aides or to non-professional or lay health workers and patients can lead to improvements in access, coverage and quality of health services at comparable or lower cost than traditional delivery models. Well documented eg. In Mozambique, Ethiopia, Malawi,

Uganda, Zambia, Brazil, India

Example Uganda

In Uganda, task shifting is already the basis for providing antiretroviral therapy. With only one doctor for every 22 000 patients and an overall health worker deficit of up to 80%,

Uganda’s nurses are now undertaking a range of tasks that were formerly the responsibility of doctors. These include: managing people living with HIV who have opportunistic

infections; diagnosing tuberculosis sputum positive; prescribing medicine to prevent other infections;

determining the clinical stage of people living with HIV; deciding whether people living with HIV have medical

eligibility for antiretroviral therapy; and managing people on antiretroviral therapy who have

minor side effects such as nausea.

In turn, tasks that were formerly the responsibility of nurses have been shifted to community health workers, who have training but not professional qualifications.

These tasks include: HIV testing; counselling and education on

antiretroviral therapy; monitoring and supporting adherence to antiretroviral therapy; filling in registers; triage; clinical follow-up; taking weight and vital signs; and explaining how to store antiretroviral drugs.

Example South Africa – rural NGO-run programme; Source: MSF, 2006

Source: MSF, 2006

Despite the evidence – and the insight that success of these programmes requires long-term planning and resourcing CHW programmes generally remain on the periphery of health

systems and are considered an emergency measure Are not sustainably funded; Simultaneously draw very high expectations and very low

investment. => NEED TO ACT ON EVIDENCE

Evidence gap: Our understanding of how CHWs interact with and impact on

households and communities is limited as is our insight into what models of delivery work best.

Policy gap I

Policy gap II:

Systematic reconfiguration of health worker teams at PHC and community levels (What services are rendered? What skills are needed for these services? Who can provide these services? What gets shifted?)

Reconfiguring specifically the role of professional nurses in this context (Clinicians and/or carers; what about medical assistants? What have nurses taken on already? What can they take on?).

Policy and evidence gap III:

Systematic engagement with and addressing of “soft” issues, i.e. impact of eg. leadership, power, motivation, organisational and professional cultures on health systems functioning, policy development and implementation, ultimately health outcomes.

This requires health systems research to resolutely step beyond traditional boundaries and start engaging systematically with social science methodology; eg. Social theory, ethnography, policy analysis.

How do we develop evidence and policy? Where and how does learning take place? Importantly by:

Building local capacity for innovative practice.

Strengthening health service and civil society capacity to generate, process and use evidence for practice and advocacy (knowledge translation).

Encouraging collaboration between diverse stakeholders.

Supporting research which encourages organisational innovation and better understanding power dimensions of organisational practice.

… until it becomes an environment in which you can actually learn from your mistakes, where you support each other more, you won’t get something like this being accepted because this is actually about saying where are we doing well but it’s also saying, and unfortunately the most is where are we not doing well….

… this needs to be an item on the agenda, this is one organisational culture we are trying to develop because unless you actually are being deliberate about it you will continue with the same.

To end, two voices from PHC services which make this point: