Task Shifting in Malawi around delivery of antiretroviral therapy

Anthony D Harries

“The Union”

Paris, France

UK Malawi

Population 60M 13M

Health funding / pa $3,000 $15

Physicians 135,000 270

Nurses 700,000 7,300

Clinical Officers ----------- 2,900

Medical Assistants ----------- 330

PLHIV 70,000 950,000

The “medicalised model” in Malawi

Doctors to deliver ARV treatment

Choice of multiple ARV regimens

Mandatory laboratory monitoring

“ LFTs, FBC, CD4-counts”

will preclude massive scale up of ART

The Key is “Keep it simple”

ART Plan (2004-2005): ART Plan (2006-2010):

main elements for the public sector

• Facilities selected and accredited for scale up

• Free ART to HIV-positive eligible patients

• One first-line ART regimen only “Triomune”

• ART delivery by clinical officers and nurses

• Standardized system of monitoring/reporting

• Quarterly structured supervision

Progress Public Sector - Malawi

Month Sites Ever Started on ART

Dec 03 9 3,000 (estimate)

Dec 04 24 13, 183

Dec 05 60 37,840

Dec 06 103 81,821

Dec 07 118 141,449

Dec 08 170 215,449

Standardised quarterly cohort reporting:Public sector Malawi: outcomes by Dec 2008

Started on ART 215,449

Alive on ART (first line ART) 142,218 (96%)

Dead (% in first 3 months) 23,044 (63%)

Lost to follow-up 23,655

Stopped 769

Transferred-out 25,763

The Human Resource Issue

2003 ART Guidelines:

• Doctors and Clinical Officers can initiate ART

• Nurses and Medical Assistants can follow-up patients

PROVIDED• They attend the national ART training

course • And pass the end of course examination

with marks of 70% or more

Data Base

• HIV Department maintains an up-to-date data base on all health care workers formally trained and certified in ART

• This date base sent to the Medical Council of Malawi and Nursing and Midwives Council of Malawi

Preparing the sites for ART

The trained clinician and nurse have to train:

1) ART clerk

2) HIV counsellors

3) Pharmacy technicians

All trainings completed

Health facilities formally accredited for ART

ARV drugs distributed and ART delivered to patients

Quarterly supervision and mentorship

• HIV Department and partners provide quarterly supervision with a focus on data validation, cohort analysis and drug stocks

• Clinical supervisors provide quarterly mentorship with a focus on diagnosis of disease, clinical staging, side effects of ART

The first two years 2004 - 2005

• System worked quite well

• 60 ART clinics, mainly in hospitals, set up

• 40,000 PLHIV ever started on ART

BUT observations and challenges:-

• As patient numbers increased, nurses took over a larger role in running ART clinics

• A strong relationship between good ART clinics and good ART clerks

• Better patient access and follow-up required decentralisation to health centres where often there were no clinical officers

The new ART Plan: 2006 – 2010:to increase ART access to 250,000 by 2010

Reduce the burden of work in hospitals:

• Reduce follow-up frequency to 2 or 3-months

• Decentralise ART follow-up to health centres

• Decentralise ART initiation to health centres

• Task shift

ART Guidelines and Human Resources

• ART Guidelines 2006:

Doctors, clinical officers and medical assistants can initiate ART

• ART Guidelines 2008:

Doctors, clinical officers, medical assistants and nurses can initiate ART

The battle was to get nurses approved to initiate ART

• Nurses and Midwives Council in favour

• Medical Council not in favour

Negotiations between HIV Department and Medical Council

National stakeholders meetingsFinally, written change in policy that was

endorsed by Secretary for Health

By the end of 2008

• Over 215,000 PLHIV ever started on ART

• 76,000 new patients started in 2008

• 170 sites in public sector delivering ART

• 84 (50%) sites = health centres

Health workers running ART clinics in public sector

Dec 06 Jun 07 Dec 07 Jun 08 Dec 08

Number on ART

81,821 110,075 141,449 184,405 215,449

FTE-Clinician 77 91 98 133 142

FTE-Nurse 86 89 107 152 163

FTE-Clerk 64 75 92 129 142

If Malawi continues to increase PLHIV on ART by 75,000 per annum

• By 2015 (MDG) the country may have 750,000 patients ever started on ART

• This may require 500 FTE clinicians and 500 FTE nurses to just man ART clinics

What is the way forward?

Treat, train and retain

1. Simple ART Delivery

• Continue to run a simple model of ART delivery and resist calls for a more sophisticated model

• Focus outcomes on the numbers retained on ART stratified by type of ART regimen

2. Ensure decentralisation is matched with quality delivery

• Compare performance of health centres against hospitals

• Compare performance of purely nurse run clinics against clinician-run clinics

FIGURE. Probability of attrition (deaths, loss to follow up and stopped) at hospital and health centres

0.00

0.20

0.40

0.60

0.80

1.00

Att

ritio

n f

rom

car

e

0 2 4 6 8 10 12 14Time in months since starting ART

Hospital

Health centres

Comparison of ART outcomes in hospital and three health centres, Thyolo, Malawi

Massaquoi et al, Trans Roy Soc Trop Med Hyg, 2009

3. Increase the number of ART clerks

• Recruit from secondary school

• Formally establish position of ART clerk with clearly defined tasks

• Emphasise the central importance of data integrity and analysis

4. Consider task shifting to lower levels of health worker

• Health surveillance assistants: (10-weeks training in general preventive activities such as vaccination and hygiene)

• In 2006, 3,800 in health sector. GFATM funds to increase this cadre over next 5 years

But, need to assess whether Health Surveillance Assistants can

follow up patients on ART

One study in Lighthouse, Lilongwe, in 2007 showed that this cadre would miss important and life-threatening side effects

CONCLUSION

• Human resource issues are crucial for the long-term sustainability of ART delivery

• Innovative solutions and clear political commitment to establish new positions