Harries AD: Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa

Médecins Sans Frontières, Medical Department, Brussels Operational Center, Rue de Gasperich, Luxembourg.
Transactions of the Royal Society of Tropical Medicine and Hygiene (Impact Factor: 1.84). 12/2008; 103(6):549-58. DOI: 10.1016/j.trstmh.2008.09.019
Source: PubMed


Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions and low motivation. In particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières' experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition and international 'brain drain'. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.

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Available from: Mit Philips, Jul 28, 2014
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    • "Most studies on this topic, task shifted only one NCD, unlike the five in Kibera.[19]Task shifting, as done in HIV care where it has been shown to be feasible, is the closest in terms of complexity.[19]There are multiple studies that demonstrate that nurses follow protocols appropriately and sometimes superiorly to physicians, but none that compare nurses directly to clinical officers.[6,20,21,22]It is likely that the Kibera nurses would perform comparably to clinical officers with similar patients if a randomized control group had been implemented. Strengths of the study are the large sample size, a stable cohort of patients that met the study's eligibility criteria, and rigorous data collection. "
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    ABSTRACT: Background: In sub-Saharan Africa there is an increasing need to leverage available health care workers to provide care for non-communicable diseases (NCDs). This study was conducted to evaluate adherence to Médecins Sans Frontières clinical protocols when the care of five stable NCDs (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) was shifted from clinical officers to nurses. Methods: Descriptive, retrospective review of routinely collected clinic data from two integrated primary health care facilities within an urban informal settlement, Kibera, Nairobi, Kenya (May to August 2014). Results: There were 3,554 consultations (2025 patients); 733 (21%) were by nurses out of which 725 met the inclusion criteria among 616 patients. Hypertension (64%, 397/616) was the most frequent NCD followed by asthma (17%, 106/616) and diabetes mellitus (15%, 95/616). Adherence to screening questions ranged from 65% to 86%, with an average of 69%. Weight and blood pressure measurements were completed in 89% and 96% of those required. Laboratory results were reviewed in 91% of indicated visits. Laboratory testing per NCD protocols was higher in those with hypertension (88%) than diabetes mellitus (67%) upon review. Only 17 (2%) consultations were referred back to clinical officers. Conclusion: Nurses are able to adhere to protocols for managing stable NCD patients based on clear and standardized protocols and guidelines, thus paving the way towards task shifting of NCD care to nurses to help relieve the significant healthcare gap in developing countries.
    Full-text · Article · Jan 2016 · PLoS ONE
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    • "There are, however , counter arguments that CHW treatment of pneumonia, if accompanied by proper supervision of CHWs, could actually decrease improper use of antibiotics (Marsh et al. 2008). Several authors (Zachariah et al. 2009; Fulton et al. 2011) have suggested that there is both professional and institutional resistance to shifting responsibilities for providing sensitive services involving powerful medical therapies to less skilled CHWs; however, the evidence base to support these assertions is not strong. "
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    ABSTRACT: Background: There has been a re-emphasis recently on community health workers to provide child health care services including integrated community case management for childhood illness (iCCM). This research analysed iCCM policy development in Kenya and in particular the types of decision-making criteria used by Kenyan policy-makers in considering whether to advance iCCM policy. Method: Data were collected through document reviews (n = 41) and semi-structured interviews (n = 19) with key stakeholders in iCCM policy including government officials, development partners, bilateral donors, and civil society organizations. Initial analysis was guided by the policy triangle with further analysis of factors affecting policy decision-making drawing upon a simple framework developed by Grindle and Thomas (Policy makers, policy choices and policy outcomes: the political economy of reform in developing countries. 1989; Policy Sci 22:213-48.). Findings: Policy development for iCCM has been slow in Kenya, compared with other Sub-Saharan African countries. At the time of the study, the Government had just completed the Community Health Training Manual which incorporated iCCM as a module, but this was the only formal expression of iCCM in Kenya. We found technical considerations, notably concerns about community health workers dispensing antibiotics to be a key factor slowing iCCM policy development, but this also overlapped with bureaucratic considerations, such as how the development of community health worker cadres may affect clinicians, as well as initial concerns about how an integrated approach might affect vertically oriented programs. International actors through agreements such as the Millennium Development Goals helped to get child survival onto the national policy agenda and such actors were active promoters of iCCM policy change. However international funders had not committed funding to scale-up iCCM policy, and this probably constrained their influence over iCCM policy debate. Conclusion: Kenyan actors' concerns about iCCM underline the importance of adapting global policies to local conditions, and also generating local evidence to inform decision-making.
    Full-text · Article · Dec 2015 · Health Policy and Planning
    • "Thus, while task-shifting to non-specialist health workers is a cost-effective way of improving outcomes in people with mental disorders, especially in low-and middle-income countries, continuing supervision, training and support from mental health professionals is required as an important component for quality of care. Yet, there can be resistance by higher cadres, given perceived lessening of hierarchal structures (Van Niekerk 2008), loss of earnings (where remuneration includes fee for services), and the additional supervisory responsibilities that more skilled staff must assume (Philips et al. 2008; Zachariah et al. 2009). Barber et al found quality improvements at public health facilities in Indonesia that had at least one physician vs those that had none (Barber et al. 2007). "
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    ABSTRACT: Abstract There is growing interest in the effectiveness of task shifting as a strategy for addressing expanding health care challenges in settings with shortages of qualified health personnel. The aim of this study is to examine the perception of stakeholders about the adequacy of training, supervision and support offered to community mental health workers (CMHWs) in Ghana. To address this aim we designed and administered self-completed, semi-structured questionnaires adapted to three specific stake- holder groups in Ghana. The questionnaires were administered to 11 psychiatrists, 29 health policy implementers/coordinators and 164 CMHWs, across Ghana, including 71 (43.3%) Community Psychiatric Nurses (CPNs), 19 (11.6%) Clinical Psychiatric Officers (CPOs) and 74 (45.1%) Community Mental Health Officers (CMHOs). Almost all the stakeholders believed CMHWs in Ghana receive ad- equate training for the role they are expected to play although many identify some gaps in the training of these mental health workers for the expanded roles they actually play. There were statis- tically significant differences between the different CMHW groups and the types of in-service training they said they had attended, the frequency with which their work was supervised, and the frequency with which they received feedback from supervisors. CPOs were more likely to attend all the different kinds of in-service training than CMHOs and CPNs, while CMHOs were more likely than CPOs and CPNs to report that their work is never supervised or that they rarely or never receive feedback from supervisors. There was disparity between what CMHWs said were their experiences and the perception of policy makers with respect to the types of in-service training that is available to CMHWs. There is a need to review the task shifting arrangements, perhaps with a view to expanding it to include more responsibilities, and therefore review the curriculum of the training institution for CMHWs and also to offer them regular in-service training and formal supervision. Key Messages • Stake holders’ perceive the training of community mental health workers to be adequate for the role they are expected to play but not the role they actually play within Ghana’s mental health delivery system. • About a third of all community mental health workers rate the quality of the supervision they receive as either low or very low and many report that they receive no feedback from their supervisors. • Stakeholders identify several challenges that hinder provision of supervision for community mental health workers • There is the need for Ghana’s policy makers and coordinators to thoroughly review the task-shifting roles and the training and supervision arrangements for all community mental health workers to ensure that quality care is provided by these health cadres.
    No preview · Article · Nov 2015 · Health Policy and Planning
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