1. Task Shifting Presented by: Dr. Peter Ngatia Director for Capacity Building, AMREF Monday, 20 th July 2011 Governance for Health Systems Development Conference Moevenpick Hotel, Dar es Salaam 18 th -22 nd July 2011

2. Human Resources for Health: Who? Human Resources for Health (HRH): The stock of all individuals engaged in promotion, protection or improvement of the health of the population Also referred to as: the health workers; the health workforce

3. A simple message: health workers save lives!

4. HUGE Burden of Disease: Few Resources

6. Estimated critical shortages of doctors, nurses and midwives, by WHO region Africa has the least density

7. Countries with a critical shortage of health service providers (doctors, nurses and midwives) Countries with a critical shortage of health service providers (doctors, nurses and midwives) 36/54 are in sub- Saharan Africa

8. The same countries are making slow progress towards the health-related MDGs Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health Organization Maternal mortality ratio per 100 000 live births in 2000

9. Tanzania Like most other developing countries- faced with multifaceted problems and challenges in the provision of health care. A shortage of skilled workforce stands out as one of the most critical matter which affects health services delivery Currently, the total available health workers to provide required health services are only 32,562 (40%) of the requirement. The effort by Government in recruiting health Workers has resulted in the reduction of gap from 68% in 2001 to 60% in 2010. There are still challenges with continuous professional development in order to ensure that the few health workers available increase in competence and deliver quality health services

10. Distribution of existing health cadres (Tz)

12. Solution 1: Increase number of health workers Training more numbers of health workers Improve education system for more candidates eligible to train for all cadres Invest in infrastructure for training facilities for all cadres of health workers Invest in innovative training methodology

13. Solution 2: Retaining health workers Improving the health workforce wages Increasing deployment of health workers Increase the budgetary allocation for health to cover better wages Have the workforce with the correct skills deployed at all levels Increase the wage bill for health workers

14. A true story is told of an orthopaedic surgeon, one of very few who practiced in 1970s who, although a brilliant surgeon, had a major weakness for alcoholic beverages that often caused him to fall asleep in the middle of an operation. Nevertheless, his patients were also wheeled out of the theatre with the operations having been done perfectly. It turned out that his assistant, an old man called Karuri who had for many years watched the surgeon at work, handing him scalpel and forceps and sutures, took over whenever his boss nodded off, doing everything exactly as he had seen the surgeon do countless times. Karuri took over the tasks of a trained health professional and did them perfectly well. This is a simple case of TASKSHIFTING. A case of TASKSHIFTING

15. Task shifting This is the rational re-distribution of tasks, where appropriate from highly qualified health workers to health workers with a shorter training and fewer qualifications to make efficient use of existing human resources. (WHO) Solution 3: Use health workers that exist efficiently and effectively

16. In 2007 consultation of national governments, civil society, professional organisations and international organisations on task shifting as a solution for global health worker crises. In 2007 the task shifting project was underway with selected countries—Ethiopia, Haiti, Malawi, Namibia, Rwanda, Uganda and Zambia implementing the task- shifting approach for HIV service delivery with notable success. Accepting task shifting as a plausable solution to the HRH crisis?

18. 1 st Global conference on task shifting was convened in January 2008 by WHO. Treat train, retain for HIV Guidelines and recommendations for task shifting were formally launched to facilitate the widespread implementation of task shifting in countries that choose to adopt the approach Towards a framework of task shifting

19. Assumptions of task shifting strategy That there is under-utilised capacity among less specialised health workers. That it is desirable and possible to change priorities or roles of less specialised health workers to include tasks from more specialised health workers, or That the number of less specialised health workers can be increased to accommodate increased responsibilities more cost-effectively.

20. Recommendations A: On adopting task shifting as a public health initiative Case study: Kenya medical training institute training trend Recommendation 1. Task shifting should be implemented alongside other efforts to increase the numbers of skilled health workers Production of HRH must ALSO be scaled up!

21. Recommendations B: Creating an enabling regulatory environment for implementation Recommendation 6. Countries could pursue a fast track strategy and simultaneously pursue long-term reform that can support task shifting on a sustainable basis within a comprehensive and nationally endorsed regulatory South Sudan  Ministry of health developed  The incorporation of task shifting policy in the training of clinical officers enables them to perform C-sections and below the knee amputations. Kenya’s Community health strategy (CHS)  Further defined the role of community health workers with modalities for supervision through CHEWs and compensation on performance of Ksh. 2000 per month

22. Recommendation C: On ensuring quality of care Recommendation 9 Countries should adopt a systematic approach to harmonized, standardized and competency based training that is needs-driven and accredited so that all health workers are equipped with the appropriate competencies to undertake the tasks they are to perform.

23. Recommendations D: On ensuring sustainability Recommendation 14 While volunteers can make a valuable contribution on a short term or part time basis, trained health workers who are providing essential health services, including community health workers, should receive adequate wages and/or other appropriate and commensurate incentives. Insert examples of barriers to this?

24. Recommendation E: On oganisation of clinical services Recommendation 16: Countries should consider the different types of task shifting practice and elect to adopt, adapt, or to extend, those models that are best suited to the specific country situation (taking into account health workforce demography, disease burden, and analysis of existing gaps in service delivery).

25. Example of roles shifted or shared? Need: universal access to HIV testing and treating Action: shift from doctor monitored therapy to nurse monitored therapy for HIV/Aids treatment Evidence: multiple studies show nurse monitored therapy not inferior to doctor monitored Where: Rwanda, South Africa, Lesotho, UK Gap: Further studies to observe management of advanced HIV infection Need to increase access to obstetric care to reduce maternal mortality Action: emergency obstetric care/surgery by clinical officers /medical officers etc Evidence: multiple studies show clinical efficacy and economic value of task shifting to clinical officers Where: Tanzania, Mozambique, Malawi Gap: Further studies on a lower cadre providing skilled delivery

26. Barriers to task shifting Professional protectionisms Doctors feel that they have many years of training and not just anyone can do a doctors job. Nurses feel their profession is invaded by nursing aids, community health workers Professional boundaries and regulation Regulatory environment is permissive of task shifting however the cadre has no legal protection for additional tasks if anything was to go wrong. USAID & ECSA-HC 2010

27. Barriers to task shifting (contd) Poor worker salaries and working conditions Seen as a ploy by governments to avoid paying the right people to do their rightful jobs. Perceived focus on HIV and AIDS makes people view task shifting as another initiative for and about HIV and AIDS which would weaken the health systems.

28. Addressing challenges 1: Protection of health workers Health legislation or administrative regulation “In Namibia a nurse cannot prescribe ART because they are bound by the clause on medications they are allowed to prescribe. If a nurse prescribes and something goes wrong they are on their own.” This situation can be addressed if professional protectionisms is reduced and rules and regulations encompass task shifting.

29. Addressing challenges 2: Protection of people receiving treatment and care Training framework and accreditation for task shifting “In Uganda ‘ task shifting is happening on a wide scale at various levels and in many forms” Midlevel health workers are providing services out of experience without formal training and guidelines. Development of frameworks for task shifting would provide for pre service and in service training for competencies assigned to these health workers.

30. Dr. Peter Ngatia Director, Capacity Building AMREF Headquarters Ph: +254 20 699 3208/9 Email: peter.ngatia@amref.org Contact