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

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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)

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1 22

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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

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11

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3 2

97

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Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

2006 2007 2008

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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