What aspects of task shifting are working well and can we build upon and replicate these achievements in Uganda? Dr Shafique Pirani University of British Columbia Project Director Uganda Sustainable Clubfoot Care Project

Problem - A global health workforce crisis World facing a chronic shortage of trained health workers. Global health workforce deficit of more than four million Shortages critical in developing nations Malawi - one doctor for every 100,000 people. Task Shifting - Global Recommendations and Guidelines, WHO 2006

Problem - A global health workforce crisis Direct correlation between numbers of people with access to health services and the numbers of health- service providers. Crisis impedes ability for “enough people, with the right skills, in the right place” Need to strengthen health systems to meet commitments of Millennium Development Goals Task Shifting - Global Recommendations and Guidelines, WHO 2006

Task Shifting: A Strategy to address the problem of a chronic shortage of trained healthcare workers Task shifting “A rational redistribution of tasks among health workforce teams whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications so as to make more efficient use of existing human resources and ease bottlenecks in service delivery.” Task Shifting - Global Recommendations and Guidelines, WHO 2006

Task shifting not new Many nations have a history of health care provision by staff who are not trained to be physicians, but who are capable of many of the diagnostic and clinical functions of medical doctors. Barefoot doctors (China) Officiers de sante (France) Feldshers (Russia)

Orthopaedic Officers, Uganda Orthopaedic Clinical Officers, Malawi

Non specialist surgeon Medical Officers at District Hospital without Surgeon Non-physician surgeons Technicos De Cirugia Nurses who have 3 yrs additional training in a program established in ? Safe ? Effective ? Cost ? Sustainable

2071 caesarian deliveries 46% by assistant med officer 54% by specialists No differences in the indications for caesarean delivery No differences in interventions associated with caesarean delivery Significant difference in superficial wound separation due to haematoma, which was slightly more common (0.35% vs 0.05%) in the group operated on by assistant medical officers

14 assistant medical officers (1995) 10,258 surgical operations 70% emergency (0.4% postoperative mortality) 30% elective (0.1% postoperative mortality) After 7 years >90% of three graduating classes of tecnicos de cirurgia stayed in rural areas Not a single physician graduating in the same years did so. Pereira et al (unpublished)

Productivity And Costs 2002 Specialist Surgeon Non-Physician Surgeon (technico) Surgeries Number of surgeons 4753 C-sections per surgeon Obstetric Hysterectomies per surgeon 47 Laparotomy per surgeon 67 Cost per surgery $144$39

Guidelines for Task Shifting (borrowed from HIV/AIDS) Define Limits Provide Training, Supervision and Referral Systems Ensure Adequate Recognition and Remuneration Develop Adapted Guidelines Simplification Engaging with Regulatory Frameworks and Professional Bodies Exploring Potential for Community Support

“To contribute to eliminating the neglected clubfoot as a significant cause of musculoskeletal disability and poverty in Uganda”

Good/Ex cellent 33% Fair/Poor67% Reoperation rate 88%

The Ponseti Method Dr Ignacio Ponseti University of Iowa

Controls Ponseti Good/Ex cellent 78% Fair/Poor22% Good/Ex cellent 85% Fair/Poor15%

Task Shifting – Paramedicals can treat clubfeet “… the Ponseti method of serial cast treatment can be employed successfully by appropriately trained healthcare professionals such as physiotherapists…”

Task Shifting – Paramedicals can treat clubfeet “ We believe that the Ponseti technique is suitable for us by non-medical personnel….”

Engaging Regulatory Frameworks and Professional Bodies Training and Supervision

Institutions Teaching Medical Schools4 Paramedical Schools2 Nursing & midwifery Schools32 Define Limits, Develop Adapted Guidelines

Clubfoot clinics in 36 hospitals Opening Arua Hospital Clubfoot Clinic Referral System Screening for foot deformity at birth

‘ I absconded from treatment because the kids father provided no support’ Mother ‘Traditionally, people think that there are unappeased spirits causing the problem.’ Practitioner treating clubfoot Exploring Potential for Community Support: Ethnocultural survey of clubfoot in Uganda

Clubfoot clinics in 36 hospitals Region Central Eastern Norther n Western Total Children treated per year by region

Ex Africa Semper Aliquid Novi There is always something new from Africa Pliny the Elder, 77AD.